PDF IASLC International Staging Project Database Account Request Form

IASLC International Staging Project Database Account Request Form

Use this form to request Institution or User account. The first data user entry below is for the Principal Investigator and must be filled out for the form to be accepted. Please email the completed form to staging@iaslc.org and webhelpiaslc@crab.org.
Please indicate the project in which you would like to participate. If you are participating in multiple staging projects, please submit a separate form for each disease site.
Submitter Information

Please complete this section even if the individual submitting the form is also requesting a user account
Name

TitleFirst NameLast Name
Email Address
Institution Information
Institution Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Fax Number

Country CodeArea CodePhone Number
Member of GCCB-II or GCCB-III Consortium?

YesNo
Principal Investigator - Data Entry System User #1
Name

TtileFirst NameLast Name
Email Address
Data Entry System User #2
Name

TtileFirst NameLast Name
Email Address
Data Entry System User #3
Name

TtileFirst NameLast Name
Email Address
Data Entry System User #4
Name

TtileFirst NameLast Name
Email Address
Data Entry System User #5
Name

TtileFirst NameLast Name
Email Address
Data Entry System User #6
Name

TtileFirst NameLast Name
Email Address

IASLC International Staging Project Description of Site Cohort Form
Please indicate the project in which you would like to participate. If you are participating in multiple staging projects, please submit a separate form for each disease site.
Site number (if known)
Name of Institution
Proposed method of data entry

Online data entryData transfer
Method of case selection

Population-based sample: Population-based sample selection involving enhancement of a population-based cancer registry with the data elements required for this study. All patients diagnosed within the study period may be included or a random sample of the same.Institution-based sample: Institution-based sample selection involving capture of information on all newly-diagnosed patients seen at the institution during the period of the study. May involve the use of an institution's tumor registry, enhanced with the data elements required for this study.Clinical series: Involving the capture of information on an inception cohort of all newly-diagnosed patients presenting to a defined clinical service during the period of the study.Other
If other, please describe:
Estimated number of new cases per year:
Additional Information

In the box provided, please describe the additional relevant information according to the instructions below, depending on the method of case selection employed.
If population-based, please describe the population coverage:
If institution-based, please describe the referral pattern:
If clinical series, please describe the clinical service, including all treatment modalities offered:
Data Transfers Only

Please complete the information below ONLY if this application is for data transfer
If this application is regarding a data set to be transferred, please complete the section below. If more than one data set is being transferred, please describe each data set separately, including any other important differences regarding patient selection.
Total patients, please designate patient totals by data set
Years of diagnosis, please designate years of diagnosis by data set
Other information regarding patient selection, please designate the information by data set
Email
example@example.com
Email
example@example.com
Email
example@example.com
Email
example@example.com
Email
example@example.com
Should be Empty:

IASLC International Staging Project Database Account Request Form

Submitter Information

Institution Information

Principal Investigator - Data Entry System User #1

Data Entry System User #2

Data Entry System User #3

Data Entry System User #4

Data Entry System User #5

Data Entry System User #6

IASLC International Staging Project Description of Site Cohort Form

Additional Information

Data Transfers Only