Request for Restricted or Encrypted Variables
 in the SEER-MHOS Data File

Part I (to be completed by Investigator) 

Name and title of investigator:	     	
Organizational affiliation:	     	
Telephone:	     	Fax:	     	Email:	     	
Project title:	     	

Project Abstract (insert here or attach as separate document):

     	

Type of variable requested:

	Contract Number 		Plan Contract Number		Plan Name		Plan Identification Number	

Please describe how these variables will be used (ex. unencrypted Plan Identification Number will be used to determine distance to care). 
     	
This project is funded by:   		NCI		DOD		Other (please specify):		

  I agree that if these variables are released to me that they will not be used to identify any individual cancer patient, or health plan.  I will publish findings from these analyses at a sufficient level of aggregation to make it impossible to identify individual healthplans, and I will not make public any information that may result in the identification by others of individual patients, or healthplans.

     		     		     	
Date	Investigator’s Printed Name	Investigator’s Signature	

Please forward this request to Health Services Advisory Group.
This can be sent via e-mail to: SEER-MHOS@azqio.sdps.org
or by surface mail:

Health Services Advisory Group
Surveys, Research and Analysis
SEER-MHOS
3133 East Camelback Road, Suite 300
Phoenix, Arizona 85016-4501

Part II (to be completed by NCI):

Name of Investigator:	     	
		
Project Title:	     	

  I have reviewed this request and agree to the release of the following unencrypted variables:

	None		Contract Number	
	Plan Contract Number		Plan Name	
	Plan Identification Number			
				
Prior to submitting an article for publication, all outside researchers who use the SEER-MHOS data are required to provide a copy of the manuscript to NCI for review to insure that there are no confidentiality/privacy issues.  

     		     		     	
Date	NCI Staff Printed Name	NCI Staff’s Signature	

NCI Staff Reviewer:  Please forward to IMS Contact at:

Part III (to be completed by IMS Staff Reviewer): 

     		     	
Date	IMS Staff Printed Name