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Are You an Internal Provider?
* must provide value
Yes
No
Internal includes MCU, MBC, and Quad Cities
IMTB Case #:
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Format: UI-MTBxxx
Has this case been reviewed by the IMTB before?
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Yes
No
If 'Yes', what was the case number previously?
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Follow the format MTBXXX
Submitter First and Last Name
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Case Submission Contact Email Address:
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Case Submission Contact Phone:
Please provide area code.
Are you the patient's physician?
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Yes
No
Patient's Physician's Name
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Physician Contact Email (if different from above)
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Physician Contact Phone (if different from above)
Please provide area code.
Today M-D-Y
What would you like to see or receive from the review process? Please Describe:
Patient's Treatment Facility
* must provide value
UI Health Care UI Mission and Blood UI Cancer Services Quad-Cities I-CAN Great River Health, Burlington, IA I-CAN Mashaka Heath, Oskaloosa, IA I-CAN Shenandoah Medical Center, Shenandoah, IA I-CAN Spencer Hospital, Spencer, IA I-CAN St. Anthony Hospital, Carrol, IA Other, define
If 'Other', Please enter the Site/Clinic Name:
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Patient MRN
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Do you have the next-generation sequencing results and a recent clinic note?
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Yes
No
Clinic note upload:
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Patient Initials
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Patient Year of Birth
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Patient Gender
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Female Male Unknown Unspecified Refused to Answer
Patient's Zip Code at Submission
Patient Diagnosis and Disease Information
Adult or Pediatric
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Adult Case
Pediatric Case
Tumor Type
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Solid tumor
Hematologic tumor and/or disorder
Solid tumor
Hematologic tumor and/or disorder
Patient Diagnosis
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What was the patient's progression-free survival (time from start of treatment until disease progression) on the most recent therapy?
Today M-D-Y Enter '01' for the day/month where not known
0 - Fully active, able to carry on all pre-disease performance without restriction 1 - Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature, e.g., light house work, office work 2 - Ambulatory and capable of all selfcare but unable to carry out any work activities. Up and about more than 50% of waking hours 3 - Capable of only limited selfcare, confined to bed or chair more than 50% of waking hours 4 - Completely disabled. Cannot carry on any selfcare. Totally confined to bed or chair
Stage I Stage IA Stage IB Stage II Stage IIA Stage IIB Stage III Stage IIIA Stage IIIB Stage IIIC Stage IV Stage IVA Stage IVB Stage IVC
CNS Head & Neck Skin-Melanoma Skin-non-melanoma Breast Lung Esophagus Stomach Colon/Rectum Pancreas Liver Kidney Bladder Prostate GYN Sarcoma Unknown Primary Other
If 'Other' Disease Site, please describe
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Hematologic malignancy diagnosis/diagnoses
Specify type of myeloproliferative neoplasm
Specify type of non-Hodgkin lymphoma
If 'Other,' specify type of hematologic malignancy
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Does the Patient have Measurable Disease?*At least one lesion that is > 1cm on CT or PET scan ( > 1.5 cm for LN)
**Excludes bone, brain and effusions.
Yes
No
Please describe the measurable disease.
* must provide value
List any current and/or prior therapies that your patient underwent, including start and end dates, in the box below.
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Please describe the patients current disease status.
Has the patient had prior cytotoxic therapies related to:
Prior solid tumor diagnosis
Prior hematologic malignancy
Prior solid tumor diagnosis
Prior hematologic malignancy
Has the patient had prior stem cell transplant(s)?
Yes
No
Autologous stem cell transplant Allogeneic stem cell transplant Syngeneic transplant
Allogeneic stem cell transplant information:
Match related Match unrelated Cord Other
If 'Other' please describe:
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List any other clinically relevant information about your patient's case (e.g. affecting clinical trial eligibility or treatment).
Is there a family history of cancer or blood disorders?
Yes
No
If 'Yes' please describe:
* must provide value
Has the patient had prior or additional germline genetic testing?
* must provide value
Yes
No
Upload germline testing report
If 'Yes' please describe:
* must provide value
Molecular Testing Information
Date of Sample Collection
Today M-D-Y
Today M-D-Y
Which Molecular Test Was Used?
Academic Medical Center Lab ARUP Caris Foundation One Guardant 360 Invitae Nationwide Children's Institute for Genomic Medicine OHSU Knight Diagnostics OncoHeme (Mayo) Prevention Genetics Strata Tempus Other
If Other or Academic Medical Center Lab, please provide additional detail
* must provide value
Brain Lung Liver Lymph Node Skin Soft Tissue Adrenal Gland Other
If Other, Please Describe the Sample Site
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Do you have additional test results (for this sample) that you would like to attach to the submission?
Yes
No
How many additional tests?
1
2
3
4
5
6
7
Date of Sample Collection
Today M-D-Y
Today M-D-Y
Which Molecular Test Was Used?
Academic Medical Center Lab ARUP Caris Foundation One Guardant 360 Invitae Nationwide Children's Institute for Genomic Medicine OHSU Knight Diagnostics OncoHeme (Mayo) Prevention Genetics Strata Tempus Other
If Other or Academic Medical Center Lab, please provide additional detail
* must provide value
Brain Lung Liver Lymph Node Skin Soft Tissue Adrenal Gland Other
If Other, Please Describe the Sample Site
* must provide value
Additional Test Result File for This Sample:
Date of Sample Collection
Today M-D-Y
Today M-D-Y
Which Molecular Test Was Used?
Academic Medical Center Lab ARUP Caris Foundation One Guardant 360 Invitae Nationwide Children's Institute for Genomic Medicine OHSU Knight Diagnostics OncoHeme (Mayo) Prevention Genetics Strata Tempus Other
If Other or Academic Medical Center Lab, please provide additional detail
* must provide value
Brain Lung Liver Lymph Node Skin Soft Tissue Adrenal Gland Other
If Other, Please Describe the Sample Site
* must provide value
Additional Test Result File for This Sample:
Date of Sample Collection
Today M-D-Y
Today M-D-Y
Which Molecular Test Was Used?
Academic Medical Center Lab ARUP Caris Foundation One Guardant 360 Invitae Nationwide Children's Institute for Genomic Medicine OHSU Knight Diagnostics OncoHeme (Mayo) Prevention Genetics Strata Tempus Other
If Other or Academic Medical Center Lab, please provide additional detail
* must provide value
Brain Lung Liver Lymph Node Skin Soft Tissue Adrenal Gland Other
If Other, Please Describe the Sample Site
* must provide value
Additional Test Result File for This Sample:
Date of Sample Collection
Today M-D-Y
Today M-D-Y
Which Molecular Test Was Used?
Academic Medical Center Lab ARUP Caris Foundation One Guardant 360 Invitae Nationwide Children's Institute for Genomic Medicine OHSU Knight Diagnostics OncoHeme (Mayo) Prevention Genetics Strata Tempus Other
If Other or Academic Medical Center Lab, please provide additional detail
* must provide value
Brain Lung Liver Lymph Node Skin Soft Tissue Adrenal Gland Other
If Other, Please Describe the Sample Site
* must provide value
Additional Test Result File for This Sample:
Date of Sample Collection
Today M-D-Y
Today M-D-Y
Which Molecular Test Was Used?
Academic Medical Center Lab ARUP Caris Foundation One Guardant 360 Invitae Nationwide Children's Institute for Genomic Medicine OHSU Knight Diagnostics OncoHeme (Mayo) Prevention Genetics Strata Tempus Other
If Other or Academic Medical Center Lab, please provide additional detail
* must provide value
Brain Lung Liver Lymph Node Skin Soft Tissue Adrenal Gland Other
If Other, Please Describe the Sample Site
* must provide value
Additional Test Result File for This Sample:
Date of Sample Collection
Today M-D-Y
Today M-D-Y
Which Molecular Test Was Used?
Academic Medical Center Lab ARUP Caris Foundation One Guardant 360 Invitae Nationwide Children's Institute for Genomic Medicine OHSU Knight Diagnostics OncoHeme (Mayo) Prevention Genetics Strata Tempus Other
If Other or Academic Medical Center Lab, please provide additional detail
* must provide value
Brain Lung Liver Lymph Node Skin Soft Tissue Adrenal Gland Other
If Other, Please Describe the Sample Site
* must provide value
Additional Test Result File for This Sample:
Date of Sample Collection
Today M-D-Y
Today M-D-Y
Which Molecular Test Was Used?
Academic Medical Center Lab ARUP Caris Foundation One Guardant 360 Invitae Nationwide Children's Institute for Genomic Medicine OHSU Knight Diagnostics OncoHeme (Mayo) Prevention Genetics Strata Tempus Other
If Other or Academic Medical Center Lab, please provide additional detail
* must provide value
Brain Lung Liver Lymph Node Skin Soft Tissue Adrenal Gland Other
If Other, Please Describe the Sample Site
* must provide value
Additional Test Result File for This Sample:
Provide any relevant information about this molecular test, the sample, or any other samples/molecular testing that was done:
Additional Hematologic Tumor & Disorder Reports + Lab Values
Bone Marrow Biopsy/Peripheral Blood Report
Flow Cytometry Blood Report
Karyotype (select all that apply)
Today M-D-Y
Mean corpuscular volume (MCV):
Additional Submission Comments/Questions
Note that we are collecting additional genomic information on your patient from the molecular testing companies (such as mutation burden, copy number variation) for clinical purposes. If you would prefer that the IOWAMTB NOT obtain that additional information, please check the box below.
How did you hear about the IMTB?
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Colleague Email advertisement Paper advertisement Other
Explain if 'Other':
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List any questions you may have in regards to your case or about the IOWAMTB process.
If applicable, select a timeline for which it would be helpful to present this case by.
Next Meeting Within the month No timeline Rush Review: Administrative Review Needed
How soon would you need your results? Typical time to completion is 2 weeks after presentation.
Within 2 weeks Within 1 week Urgent
If urgent, would you prefer the MTBs recommendation without presentation (patients are reviewed by the MTB without collaboration with Kansas University, which may provide you with a faster response)?
Yes
No
If 'Urgent', please provide requested timeframe and reason for request:
Indicate how you would like to receive your patient's recommendation letter.
mail
email notification to physician & submitter
mail
email notification to physician & submitter
Mailing Address for Response:
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Mailing Address for Response:
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Mailing Address for Response:
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