Dear Investigator
Thank you for your interest in the SEER-Medicare data.  Please use the application materials below to request SEER-Medicare files.    In order to facilitate the review process, you must complete and provide all items on this form.  Incomplete applications will be delayed.  You must submit this completed form electronically to the SEER-Medicare contact along with a cover letter, completed and signed Data Use Agreement (DUA), and, if necessary the  request for restricted variable form . The original signed DUA must also be mailed to the SEER-Medicare contact.   Instructions for submitting a request can be found at http://healthservices.cancer.gov/seermedicare/obtain/requests.html .
Thank you
NCI SEER-Medicare Staff
Questions should be sent to the SEER Medicare contact:
Elaine Yanisko
yaniskoe@imsweb.com

Application Checklist

To be sent by email attachment to the SEER-Medicare contact:

	Cover letter

	Application:

	  Your description of the project must include:	
o	a statement of main hypothesis/research question
o	a description of study subjects and cancer sites/phases to be included in the analysis
o	a brief explanation of key variables and analytic methods to be used
o	a description of the personnel involved
o	a timeline for completion

	   You must include an explanation of data storage and protection.
	
	Completed and signed Data Use Agreement (DUA)

	Request form for restricted variables (if applicable)

	Letter from funder (if applicable)

To be sent by regular mail to the SEER-Medicare contact:

	Completed and signed DUA

	Completed and signed request form for restricted variables (if applicable)

Please send any questions to the SEER-Medicare contact:

Elaine Yanisko
IMS, Inc.
12501 Prosperity Drive, Suite 200
Silver Spring, MD  20904
yaniskoe@imsweb.com

APPLICATION FOR SEER-MEDICARE DATA
I.  Contact information: (please complete all information)
Principal Investigator:
Name:		
Institution:		
Address:		
		
Email:		Phone:		Fax:		
Student /fellow contact:
Name:		
Institution:		
Address:		
		
Email:		Phone:		Fax:		

II. Project Description:
A.  	Title

B.	Brief  overview of your project (one or two sentences)

C. 	Description of the Project (no less than 1 page, no more than 5 pages).  Please include: statement of main hypothesis/research question, description of study subjects and cancer sites/phases to be included in the analysis, a brief explanation of key variables and analytic methods to be used, description of the personnel involved, and timeline for completion. 

D. 	Data Storage and Protection  Please provide an explanation of where the data will be stored and how they will be protected from unauthorized access.  This should include assurances that no attempt will be made to identify patients or providers and assurances that publications and presentations of the data will not allow identification of patients or providers. 

E. 	Funding Source    If your organization is a consulting firm, contractor, or pharmaceutical company, then your application must include a letter from the funder indicating that you are free to work and publish your findings without limitations by the funder.

F.	Restricted Variables  Selected variables are not released without the permission of the Principal Investigator of each of the SEER Registries.  These variables include census tract of the patient, zip code of the patient, physician or hospital, and unencrypted provider numbers. If you are requesting access to any of these variables, you must also submit the request form for restricted variables.  Please see http://healthservices.cancer.gov/seermedicare/privacy/variables.html for information.  NCI will provide a researcher with contact information for each of these registries, however it is the responsibility of the researcher to obtain permission from each registry.

 

III.   Data Files Requested: 

Please list specific SEER-Medicare data files and years of data required
 	(Note:  Medicare claims prior to 1998 are available only for cases diagnosed with cancer before 2003)
Name of file	Years available	Years requested	
PEDSF (SEER cases)	1973-2005		
MEDPAR	1986-2006		
Outpatient	1991-2006		
Home Health (HHA)	1991-2006		
Hospice 	1991-2006		
NCH (physician/supplier)	1991-2006		
DME	1994-2006		
SUMDENOM
5% non-cancer sample	1986-2005		
SUMDENOM
5% cancer sample	1986-2005