Bristol Receipt of Scan Form

This form is to be used only by the Bristol Scanner Centre to notify the Trial Co-ordinator that they have recieved a CT/MRI scan from a scanner centre participating in the PET-NECK trial.

Procedure to be Used Upon Receipt of CT-MRI Scans - SOP to be used by the Bristol Royal Infirmary centre when receiving scans to be read from other centres

Patient Trial Number (3-digit)

Patient Initials (If known)

Scan Transfer Report Code (4-digit)

Diagnostic Staging CT Scan

Diagnostic Staging MRI Scan

Response to CRT CT Scan

Response to CRT MRI Scan

A Completed Patient Scan Transfer Form

Date Received

Comments (Optional)

Form Completed By (Name)

Form Completion Date

Privacy notice

The data provided is used solely for the PET-Neck trial

The University of Warwick is the Data Controller of any information you have entered on this form and is committed to protecting the rights of individuals in line with Data Protection Legislation. The University's Data Protection webpages provide further information on your rights and how the University processes personal data. If you wish to submit a data subjects rights request, make a complaint or report a suspected personal data breach, please contact the University’s Data Protection Officer by email at infocompliance@warwick.ac.uk.

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Clinical Trials Unit

Bristol Receipt of Scan Form

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