Facility ID Number
Registry Case Number
Patient First Name
Patient Last Name
Exam Date | These fields are filled in automatically from the case registration form. |
A. General Information |
*Type of Study | Select the appropriate response. |
*Did technique meet ACR guidelines? | Select the appropriate response. Click the  icon for details. |
*Referred from incomplete colonoscopy | 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. |
Physician NPI
| These fields are filled in automatically from the physician directory. |
*Patient’s Width (measured from scout at widest point) | Indicate the patient's width in centimeters at the widest point, as measured from the scanned projection radiogram (e.g. scout, surview, topogram or scanogram). Range: 5-70. |
Scanner Name | Select a scanner from the list to automatically populate the Scanner Manufacturer, Detector Rows, Detector Row Size, CTDIvol, Slice Thickness, and Interval fields.
See Manage Scanners for how to create and maintain the Scanner dictionary. |
*Scanner Manufacturer | If the value you want to enter does not appear in the drop-down list, click Other. A field will appear in which you can enter the value. It must be 100 characters long or less. |
*Detector Rows
*Detector Row Size (mm) (e.g. 8 x 1.25 -> 1.25; 16 x 0.75 -> 0.75) | If the value you want to enter does not appear in the drop-down list, click Other. A field will appear in which you can enter the value. |
*CTDIvol | Enter the CTDIvol in mGy as displayed on the console. Range: 0.01 – 999.99. |
*Slice Thickness
*Interval | If the value you want to enter does not appear in the drop-down list, click Other. A field will appear in which you can enter the value. |
*IV Contrast | Indicate whether IV contrast was given. |
*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. If Yes is selected then the Polyp form must be completed. |
*Entire colon and rectum in scanned field of view | Select the appropriate response. |
*Is one or more segment non-diagnostic? | If Yes is selected then at least one reason must be indicated.
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*Colonic perforation | If Yes is selected then etiology, location, and whether patient was symptomatic from perforation must be indicated. |
*Clinically Significant Extracolonic Finding(s) (not otherwise known based on the history provided or based on a prior imaging procedure at the institution) | Select the appropriate response. |
C Score | Select the appropriate response. |
Name of Person Who Completed the Paper Form | Enter the name of the person who collected the data for this exam. If this name has not been previously entered in a case record, then enter the person’s first and last name. In the future, the name will appear in the drop-down list for this field. If the name has been previously entered, click the arrow and select it from the drop-down list.
Note: Please populate this field even if paper forms were not used. It can contain the name of the person completing the on-line data submission. |
Name of person submitting form
Submission Date | These fields are filled in automatically. |
Exam Form appears. You can also access the exam form by clicking Exam under Data Collection in the CTC Registry menu. 