BREAST CANCER SURVEILLANCE CONSORTIUM 
MANUSCRIPT AND GRANT PROPOSAL FORM

ADMINISTRATIVE

1. General information about the proposal

Date proposal submitted to the BCSC:		

Project title: 		

Short title (5 words or less):		

Project leader name:		

Project leader affiliation/ organization:		

Project leader address:		

Project leader	 email address:		

Project leader phone number:		

2. List all collaborators associated with this proposal (add rows if more than 8):
Name	Affiliation	Email Address	Will this person be part of the small working group?** (YES, NO,  or N/A)	

				

				
				
**Only applicable for a manuscript that arises from the use of pooled BCSC data from one or more consortium sites that use the SCC to conduct analyses (or the lead investigator is a member of the BCSC).

3. Proposed Timetable: 
Date of proposed initiation: 	____________________________

Proposed completion dates:	____________________________

Anticipated deadlines (if applicable): ______________________

4. Purpose of this request (Double-click boxes to mark all that apply):
	Data analysis for manuscript           Target journal: ____________________________	

Preliminary data for grant proposal	

Inputs/calibration data for simulation, decision analysis, or cost-effectiveness model	

Development of statistical methods for publication:   Target journal: ______________	

Development of statistical methods – Other:   Please specify: ___________________	

Other:         Please describe: _____________________________________________	

5. Which registries will be included in this study? (Double-click boxes to mark all that apply):
	Colorado (Denver)		San Francisco	

New Hampshire	
	
Vermont	

North Carolina	
	
Western Washington (Group Health)	

New Mexico			

6. Would you prefer an analyst from the SCC do the analysis? (Double-click appropriate box):
	YES (please skip to question #8)  	

NO, I would like a dataset sent to me, but will perform the analysis in collaboration with the Statistical Coordinating Center
             Please explain how you will store and protect BCSC data from unauthorized access:
             ____________________________________________________________
             ____________________________________________________________	

NO, I would like a dataset sent to me with minimal consultation with the Statistical Coordinating Center 
            Please explain how you will store and protect BCSC data from unauthorized access:
             ____________________________________________________________
             ____________________________________________________________	

Other (please describe) ______________________________________________	

7. If you would like a dataset sent to you, please indicate the type of data request. Note that any data request that includes dates, zip codes, specific ages >89 years or masked BCSC site identifiers will require completion of a HIPAA data use agreement following approval of your proposal. (Double-click boxes to mark all that apply).
	De-identified data/ aggregate data	

De-identified individual level data (without dates, zip codes, specific ages >89 or BCSC site IDs)	

Limited dataset: De-identified individual level data with: (mark all that apply):	
	Dates	
	Specific age >89 years	
	Zip codes (will generally not be released without careful  consideration & protection in place)	

Other     (please describe) ___________________________________	

FUNDING (Only applicable for projects not directly funded by the BCSC)

8. Do you have funding to support BCSC efforts for this project? Lack of funding will not influence whether or not a project is approved. However, priority in the queue (for starting the project) is given to projects that can fund BCSC efforts. (Double-click boxes to mark all that apply).

	Yes, I have sources of funding (please state all sources):
Source: _________________  Start & end dates (month/yr - month/yr) ___________
Source: _________________  Start & end dates (month/yr - month/yr) ____________	
	No 	
	Not needed	
	Other (please describe): ___________________________________________________	

RESEARCH OBJECTIVE/MAJOR HYPOTHESES:

9. Please fill out the content areas of your proposed research below.  Proposal length should preferably be no more than 3 pages, excluding mock tables, and should not exceed 10 pages.

Specific Aims

Background

Methods:

Study Years

Inclusion/exclusion criteria

Power analyses

Analytic plan

List of key variables

Mock Tables

To be completed by the SCC:

What is the assigned Project Number? _____________

Date of Steering Committee Review:     _____________

Steering Committee Action:
 Approved	 Not Approved	 Conditionally Approved (state reason: _____________)

Is this proposal a: 	
 Grant
 Manuscript 		
 Data Request		

Is the lead investigator from:	
 The BCSC	
 External to BCSC
 Ancillary grant (if checked, please answer the questions below):
                      What is the name of this grant? (e.g., FAVOR, CISNET) _____________
                       Is this grant using BCSC data? (YES/NO)                _____________

What is the current status of the project:
 In analysis
 In Queue
 Completed   

SCC analyst needed?				
 YES (who?) _____________ Should s/he be added to the author list? _____________	
 NO

SCC Programmer needed?			
 YES (who?) _____________	
 NO

Type of data requested:
 N/A – data not requested – SCC will do the analysis
 Aggregated de-identified data
              Data contains reader, site, and/or facility IDs
 De-identified individual level data (w/o identifiers – e.g., no zip codes, ages >89 or site identifiers)
 De-identified individual level data with dates, specific age>89, zip codes, or masked BCSC identifiers

If data was requested, has a call been made delineating points in the Synopsis document?
 YES
 NO
 Not applicable