Get Ia Shri Melanoma Reporting Form 2014-2025

This guide provides a comprehensive overview of how to fill out the IA SHRI Melanoma Reporting Form online. It is aimed at ensuring accurate and complete reporting of melanoma cases to the State Health Registry of Iowa.

Follow the steps to accurately complete the melanoma reporting form

1. Press the ‘Get Form’ button to access the melanoma reporting form and open it in your preferred editor.
2. In the Dermatology Office Contact Information section, provide the name of the reporting dermatology office, along with a phone number, date, contact individual, and the dermatologist who diagnosed the melanoma.
3. Next, fill out the Patient Demographic Information field. This includes the patient's last name, first name, middle initial, address, city, state, zip code, date of birth, and social security number. Ensure to list the insurance provider, sex (male, female, or other), marital status (married, divorced, widowed, or unknown), and race.
4. In the Tumor Information section, specify the date of diagnosis, primary site, laterality (right, left, midline, or unknown), and whether there is ulceration. Indicate the histology, maximum tumor diameter size, Breslow's depth of melanoma, and information related to satellite nodules, regional lymph node involvement, and in-transit metastasis.
5. Complete the Tumor Mitotic Rate field. For treatment details, indicate whether the patient had a biopsy, immunotherapy, chemotherapy, or radiation, along with any relevant dates and facility names.
6. Indicate if the patient had a re-excision or an excision, providing relevant facility names if applicable.
7. In the Additional Information section, specify if the patient has a history of previous melanoma and whether the current case is a new primary melanoma or recurrent.
8. Finally, complete the form by providing the name and phone number of the dermatologist completing the form.
9. Once all fields are filled accurately, save your changes. You can then download, print, or share the form as needed. Ensure all pertinent path reports are gathered before submitting.

Complete the IA SHRI Melanoma Reporting Form online to ensure proper reporting and follow-up.