I. REQUESTOR INFORMATION

Principal Investigator: _________________________________________________________

Department: ________________________________________________________________

Affiliation: Faculty Research Staff	Student

Contact Number: _______________________	Email: ____________________________

II. RESEARCH STUDY INFORMATION

Title: _______________________________________________________________________

Timeframe of Study:	_______________________	Date Data Needed: __________________

Plan of Study: Period of Data Requested: ______________________________________________________

III. DATA REQUESTED
Are you requesting confidential information?

IV. DATA AVAILABILITY AND APPROVAL

The data requested is available and can be approved for consideration.

The date requested is not available and not within the scope of the Cancer Registry.

_______________________________________________	____________________
Signature of Cancer Registry Manager	Date

V. Assurance

I assure that the information obtained will be utilized in accordance with the plan of study and all confidential information will be protected.

_______________________________________________	____________________
Signature of Principal Investigator	Date

VI. Other Approved Available Data Fields

Initials:	_______________
Cancer Registry Manager

NON-CONFIDENTIAL DATA

Patient Demographic Data (Please Check Requested Data)
Sex	Race	Number of Live Births
Tobacco Use	Cigarette Pack Years	Vital Status
Number of Primaries	Age at Diagnosis	Diagnosis Zip
Cause of Death	Diagnosis State
Place of Diagnosis	Ethnicity
Case Specific Data (Please Check Requested Data)
Site Code	Date of Diagnosis	Family History of this Cancer
Menopausal Status	Class of Case	Primary Payer
Class of Case	ICD-0 version	Topography
Histology	Tumor Grade	Tumor Marker 1
Tumor Marker 1	Laterality	Diagnostic Confirmation Code
Tumor Size	Regional Nodes Positive	Regional Nodes Examined
Sites of Metastases	Summary Stage	TNM Best Stage
Other Primaries
Case Sequence Number
Therapy Data
Treatment Composite—First Course	Treatment Composite--All
Follow-Up Information
Recurrence (Date/Type)	Vital Status	Cancer Status (active vs non)
Date of Last Contact

CONFIDENTIAL DATA

Please add confidential data fields requested:

_______________________________________________	____________________
Approval/Signature of Cancer Registry Manager	Date