Development of an Atlas of Cancer in Haryana State
Registration Form to be completed by Potential Participating Centers
 Note * Fields are mandatory
1.Name of the Institution *:    
Postal Address:
 
City*
District*
State*:   
Telephone:
Fax:
Email*:  
2.Name of Head of Institution:
3.PI, Co-PI Name & Designation
NameDesignationDepartment
Principal Investigator *
Co-Principal Investigator 1
Co-Principal Investigator 2
Faculty in Charge
4.Brief profile of the Institution:
Number of In-Patient Beds:
Total Out-Patient attendance:
Total Registrations:
Total Proved Malignancies per year:
 
 
 
 
5.Department of Pathology:
Number of Specimens/Biopsies/Smears (non-malignant and malignant) reported during the year 2017 :
Total
(Malignant & Non-malignant)		Malignant
Histopathology Specimens/Biopsies
Cytology Smears including FNAC    
Haematology Smears
(including Peripheral Smear/Bone Marow)		    
Total   
6.Number of patients treated during the year 2017 at Departments (if present) of: 
Medical Oncology:
Radiation Oncology :
Surgical Oncology:
 
 
 
Any relevant information: 
 
Name of Head of Department 
Radiation Oncology :
Medical Oncology
Surgical Oncology:
Pathology:
 
 
 
 
Completed By :*         Completed Date :