Request for restricted or encrypted variables on the SEER-Medicare 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:

  	patient census tract 	      	unencrypted physician identification numbers (UPINs)	
  	patient zip code	      	unencrypted hospital provider numbers	
  	provider zip code			
	hospital zip code			

Why these variables are needed:
     	

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, hospital or physician.  I will publish findings from this analysis at a sufficient level of aggregation to make it impossible to identify individual patients and providers, and I will not make public any information that may result in the identification by others of individual patients, hospitals or physicians.

     		     			
Date	Investigator’s printed name	Investigator’s signature	

Name of investigator:	     	
Project title:	     	
SEER PI:	     	

Part II (to be completed by the SEER PI):

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

	None	
	patient zip code	   	unencrypted physician identification numbers (UPINs)	
	patient census tract	   	unencrypted hospital provider numbers	
	provider zip code			
	hospital zip code			

Prior to submitting an article for publication, all outside researchers who use the SEER-Medicare data are required to provide a copy of the manuscript to NCI for review to insure that there are no confidentiality/privacy issues.  If such a manuscript is received, would you like the review to be done by:    yourself     NCI staff?

     		     		     	
Date	SEER PI Printed Name	SEER PI signature	
     				
Registry			

Please forward this approval to Elaine Yanisko at IMS.  
This can be sent via e-mail to: yaniskoe@imsweb.com
via Fax : 301-680-8304 
or by surface mail:

	Elaine Yanisko
        	Information Management Services, Inc.
        	12501 Prosperity Drive
        	Suite 200
        	Silver Spring, MD 20904