Paul Strickland Receipt of Scan Notification Form

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

Procedure to be Used Upon Receipt of PET-CT Scans - SOP to be used by the Paul Strickland Scanner Centre when receiving scans to be read from other centres

Patient Trial Number (3-digit)

Patient Initials (If known)

4-digit Dicom Form Code

An anonymised PET-CT scan

A completed Dicom Form

An anonymised report

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

Paul Strickland Receipt of Scan Notification Form

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