CRGC Data Inquiry Form

The Cancer Registry of Greater California is a Program of the Public Health Institute

Initial Request Form for

Confidential Cancer Registry Data

Thank you for your interest in obtaining data from the Cancer Registry of Greater California (CRGC). Please provide the following information about the project that prompts your interest in cancer registry data, and CRGC research staff will contact you within 5 business days to discuss your request. If you have any questions, please email:

RESEARCH@CRGC-CANCER.ORG

Contact Information

Your Name

Principal Investigator (PI) Name

PI’s Organizational Affiliation

E-mail Contact

Phone Number

Numbers only, no dashes or parentheses

Basic Information

Project Title

Study Objective or Purpose

Use exact wording from grant proposal or IRB, if possible. Type or attach abstract.

Specifications

Cancer Sites of Interest

Will the study involve using cancer registry data to contact patients?

Yes No Not yet determined

Is funding for the study awarded, pending, under review or being proposed?

Will the study involve linkage of cancer registry data with other data resources?

Yes No Not yet determined

If the study will require linkage of cancer registry data with other data resources, explain or describe these resources.

Which CRGC research services would support the study?

Compilation of a Dataset Collection of Medical Records or Pathology Reports Engagement of one or more Certified Tumor Registrars Support of Cancer Registry Staff (central or field staff) and/or Survey Research Professionals Project Management Data Analysis Support Other

Check any/all that may apply, leave blank if not applicable

Specify other support needed

Do you have any initial questions for CRGC research staff?