Patient Survivor and Survivor Cohort Submission Form

The Epidemiology and Genomics Research Program (EGRP) is compiling a list of cancer patient and/or survivor cohorts to foster awareness and encourage collaboration when feasible. If you have information about a cohort you would like to be considered for inclusion on this list, submit as much information as possible through the form below. For questions, contact Joanne Watters Elena, Ph.D., M.P.H.

Study/Cohort Title: * Contact Person: * E-mail Address: * Additional Contact Person: Additional E-mail: Study Website (if applicable): Number of Enrolled Cancer Patients/Survivors: * Years of Diagnoses of Enrolled Cancer Patients/Survivors: * Approximate Years of Follow-up: *

Cancer Sites Represented:

Other Sites - Please Describe:

Biological Specimens Collected:

Blood/Blood Fraction Buccal Cells Normal Tissue Germline DNA

Formaline Fixed Tumor Tissue Fresh Frozen Tumor Tissue Urine

Treatment Outcomes Measures:

Physician/Medical Record Reported

Symptom Assessment Acute Medical Event Late Medical Event Quality of Life Cancer Recurrence Death Other

Patient-Reported

Symptom Assessment Acute Medical Event Late Medical Event Quality of Life Cancer Recurrence Death Other

Co-morbidities at Study Entry:

Diabetes Heart Disease

Pulmonary Disease Other

Lifestyle Factors:

Smoking Alcohol Use Diet Physical Activity

Body Mass Index Weight Loss/Control Other

Treatment Data:

Surgery Radiation Chemotherapy

Hormonal Therapy Bone Marrow/Stem Cell Transplant Other

Treatment Data Assessed By:

Administrative Claims Data Electronic Record Chart Abstraction

Patient Reported Questionnaire Other

Is the study open to collaboration? Yes No

If yes, who should interested investigators contact to proceed?

Please feel free to provide any additional information you wish:

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Last Updated: 17 Aug 2012

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