Facility ID Number
Registry Case Number
| These fields are filled in automatically from the case registration form. |
Case Registration Date
| Enter the date the paper form was completed.
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3. Patient Information |
SSN | To use the patient’s SSN, select the SSN radio button and enter the ID in the format NNN-NN-NNNN where N is a digit; all digits are required. (Note: Hyphens are not required for file upload submissions). |
Use Other Identification
Description
| Enter the Other Identification field, and a description of the code, such as Social Insurance Number, in the Description field. Entries in these fields cannot exceed 50 characters. |
*Last Name*First Name
| First and last names must be 45 characters or less. At least two characters must be from the characters "A"-"Z", "a"-"z", or a single quote ('). Additional characters may include a hyphen. |
Middle Name
| Middle Name is optional. If entered, it must start with a letter. The remaining characters can be letters, or the characters" ' ", "-", or "." |
Old Medicare Beneficiary ID (MBID)
| Indicate the the patient's Medicare Beneficiary ID issued prior to April 2018. The format is primarily numeric, with 1-2 letters proceeding or following them. |
New Medicare Beneficiary ID (MBID)
| Indicate the the patient's Medicare Beneficiary ID issued after April 2018. This will usually be a combination of letters and numbers, 11 characters long. |
*Date of Birth
| Date of Birth must be at least three weeks prior to the current date.
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*Patient Sex
| Select the appropriate response.
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Race
| Enter the patient’s race as identified by the patient. If the patient identifies with more than one race, select Other. This field is optional. |
Patient Ethnicity (Hispanic Origin)
| Enter whether the patient is of Hispanic origin, as identified by the patient. This field is optional. |
Health Insurance
| Select the version of health insurance of the patient, if available.
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Education level
| Select the patient's level of education, if available.
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COVID vaccination/vaccination date
| Indicate if the patient has received the COVID vaccine and the date of vaccination, if available.
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COVID vaccine manufacturer | Select the appropriate response. |
COVID vaccine site | Enter the location where the patient received the COVID vaccine, if available. |
*Examination Date | Enter the date the exam was completed in mm/dd/yyyy format. The date must not be greater than the current date. |
5. General Information |
*Type of Study | Select the appropriate response. |
*Interpreting Physician
| The physician’s name must be selected from the drop-down list. For a physician to be listed as the interpreting physician, he or she must be listed as a CTC participant in the physician dictionary. Refer to Manage Physicians and Add Physicians to an Individual Registry for instructions on listing a physician as a CTC participant.
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Did technique meet ACR guidelines? | Select the appropriate response. Click the  icon for details. |
Referred from incomplete colonoscopy | Select the appropriate response. |
*CTDIvol | Enter the CTDIvol in mGy as displayed on the console. Range: 0.01 – 999.99. |
*Supine image acquisition
*Prone image acquisition
*Decubitus image acquisition | Select the appropriate response. |
B. Post Examination and Adverse Events |
*At least one polyp >= 10 mm | Select the appropriate response. |
*Colonic perforation | If Yes is selected then etiology, location, and whether patient was symptomatic from perforation must be indicated. |
C Score | Select the appropriate response. |
| E Score | Select the appropriate response. |
