Comprehensive Cancer Center Cancer Concerns Workgroup

Dashboard · Concerns · Intake Form

Cancer Inquiry Intake Form

Step 1 of 17 · Complete sections A through E. Section A remains editable; original values are preserved in the audit log.

All fields are required unless (optional) appears next to the label.

Form Approved — OMB No. 0920-0879 · Exp. Date 01/31/2024. This intake form follows CDC/ATSDR's Guidelines for Examining Unusual Patterns of Cancer and Environmental Concerns.

ATracking Information

How did the inquirer initially make contact?
Was this concern forwarded from another agency?

Staff member who answered the initial inquiry

What staff member answered the initial inquiry?

Inquirer (basic contact)

Inquirer Category
As described by the inquirer at first contact.

BInquirer's Information

Preferred Method of Communication (optional)

CArea of Concern

Define the geographic area of concern.

DCancer of Concern

What type(s) of cancer are reported?
Is the given year of diagnosis an estimate or an exact year? (optional)
Are the cancer cases adult, pediatric, or both?

EExposure of Concern

Was an environmental concern mentioned?
What is the pollutant, contaminant, or environmental toxicant of concern?
Is the environmental concern related to any of the listed location types?

Files/Documents (optional)

Up to 5 files, 25 MB each
Cancel

On submit, the original Section A values are preserved in the audit log, and an email notification is sent to the Admin role to assign the next task (Initial Determination).