ALABAMA DEPARTMENT of PUBLIC HEALTH
 
Alabama Statewide Cancer Registry - Data Revision Form

Alabama Statewide Cancer Registry

This form is to be used to report updates or changes made to previously submitted abstracts.

PLEASE DO NOT RESUBMIT CASES VIA MONTHLY DATA SUBMISSION

You can still send update information in this form through online data transfer account.

* Reporting Facility

* Registrar Completing Form:

* Patient Name: (Last, First, Middle)

* Medical Record Number:

* Date of Birth (yyyymmdd):

* Date of Last Contact (yyyymmdd):

* Vital Status:

Alive
Dead

* Cancer Status

Negative
Positive for Disease
Unknown

Data Item to Be Revised Information
Please enter the data item to be revised and the revised information in the boxes provided below.

1. Data Item to Be Revised

1. Revised Information

2. Data Item to Be Revised

2. Revised Information