Skip to Main Content

* indicates required field

I. STUDY INFORMATION

Available information pre-populated from F1
All fields required

Section A. Study Request Information

Services being requested? (Please check at least one option)
(Please limit to 150 words)
What types of specimens do you want deidentified pathology reports of?
Will a codebook or data dictionary be provided?
For tissue requests, what tissue-based studies will you be performing?
If yes, then additional processes will need to be followed and regulatory documentation will be required.

Section B. Case Eligibility Criteria

Table 1: Cancer Information

Is a comparison group needed?
Does eligibility vary by site?
Complete the index case eligibility criteria in Table 2. Index cases are the primary group being studied. If data, whole slide images (WSIs), pathology reports, and/or tissue are being requested for a comparison group, complete fields in the Comparison Group column of Table 2. For example, in a study comparing cancer cases among Black individuals with cancer cases among White people, the Black cases are the index cases, and the White cases are the comparison group cases. If you are requesting comparison group cases, these criteria and counts should be added to far right column of Table 2. For each additional cancer site being studied (e.g., nasopharynx, oropharynx, etc.), you will be asked to complete a separate Table 2.

Table 2: Case Selection eligibility

* For tissue requests over 200 total cancer cases, the request will need to be fulfilled over multiple calendar years.

Eligibility Criteria Index Cases Comparison Cases
Sex
Minimum Age (years)
Maximum Age (years)
Stage at Diagnosis (select all that apply)
Maximum Survival Time (months)
Minimum Survival Time (months)
Earliest Year of Diagnosis (YYYY) Cases diagnosed between 1 year ago and 9 years ago.
Cases diagnosed between 1 year ago and 9 years ago.
Most Recent Year of Diagnosis (YYYY) Cases diagnosed between 1 year ago and 9 years ago.
Cases diagnosed between 1 year ago and 9 years ago.
Only Include First Primary Cancer
Allow Synchronous Multiple Primaries
Allow Metachronous Multiple Primaries
Allow Neoadjuvant Treatment
Types of Neoadjuvant Treatment Allowed (check all that apply)
Procedure Types Allowed (check all that apply)
Allow Cases With Only Biopsy Tissue
ICD-O-3.2 Morphology Code(s) Excluded*
Biomarker Restrictions
(ex: triple negative breast cancers) For a list of biomarkers captured by SEER, refer to https://apps.naaccr.org/ssdi/list/)
(ex: triple negative breast cancers) For a list of biomarkers captured by SEER, refer to https://apps.naaccr.org/ssdi/list/)

Table 2(a): Breast

* For tissue requests over 200 total cancer cases, the request will need to be fulfilled over multiple calendar years.

Eligibility Criteria Index Cases Comparison Cases
Sex
Minimum Age (years)
Maximum Age (years)
Stage at Diagnosis (select all that apply)
Maximum Survival Time (months)
Minimum Survival Time (months)
Earliest Year of Diagnosis (YYYY) Cases diagnosed between 1 year ago and 9 years ago.
Cases diagnosed between 1 year ago and 9 years ago.
Most Recent Year of Diagnosis (YYYY) Cases diagnosed between 1 year ago and 9 years ago.
Cases diagnosed between 1 year ago and 9 years ago.
Only Include First Primary Cancer
Allow Synchronous Multiple Primaries
Allow Metachronous Multiple Primaries
Allow Neoadjuvant Treatment
Types of Neoadjuvant Treatment Allowed (check all that apply)
Procedure Types Allowed (check all that apply)
Allow Cases With Only Biopsy Tissue
ICD-O-3.2 Morphology Code(s) Excluded*
Biomarker Restrictions
(ex: triple negative breast cancers) For a list of biomarkers captured by SEER, refer to https://apps.naaccr.org/ssdi/list/)
(ex: triple negative breast cancers) For a list of biomarkers captured by SEER, refer to https://apps.naaccr.org/ssdi/list/)

Section C. Specimen Selection and Processing

No tissue selected

Table 1: Study Tissue Selection and Processing Requirements

Requirement Primary Tumor Non-Tumor
(complete column if applicable)
Metastatis
(complete column if applicable)
Tissue Requirements
Requirement
Preferred Specimen Site Term(s) (ex: lymph node, breast, etc.)
Total Amount of Tissue Needed (microns)
Number of Blocks Needed
Specimen Selection
Minimum Tumor Cellularity (%)
Maximum Tumor Necrosis (%)
Specimen Processing Tissue processing requested
(if checked, answer below)
Unstained slides number (total)
Unstained slides thickness (microns)
(if checked, answer below)
H&E-stained slides number (total)
H&E-stained slides thickness (microns)
H&E-stained slides level ratio (number of unstained slides to each H&E-stained slide)
(if checked, answer below)
Scrolls number (total)
Scrolls thickness (microns)
(if checked, answer below)
Number of sections (total)
Ribbons thickness (microns)
(.svs images generated via Leica/Aperio scanners)
Scanning Magnification
Maximum Number of H&E-Stained Slides per Case to Scan
Pathologist Prescreening and Selection

II. FUNDING INFORMATION

Section A. Funding Information

A funding support letter is required to show proof of grant or other funding. If the project is funded by NIH, then a data sharing plan is required. For further details, refer to NIH Data Management and Sharing Policy.
Is the study funded?
If Yes or Pending, complete Table 1
A funding support letter is required to show proof of grant or other funding. If the project is funded by NIH, then a data sharing plan is required. For further details, refer to NIH Data Management and Sharing Policy.

Table 1: Sources of Funding

III. STUDY PERSONNEL

Section A. Currently Listed

Study Team

Institution Type:

Section B. Data and Tissue Recipients

Recipient Clinical Data Contact Information

Institution Type:

Recipient Laboratory Contact Information

Institution Type: