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Development of an Atlas of Cancer in

A Project of the National Cancer Registry Programme

(Indian Council of Medical Research)

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Proforma to be completed by Potential Participating Centres

(Fields in Red are mandatory)

1. Name of Institution

Postal Address

Address

City

State

Pincode

Telephone No.

Fax

e-mail

2. Name of Head of Institution

3. Name and Designation of
Principal Investigator

Co-Principal Investigator

4. Name and Designation of Faculty in charge

5. The most crucial part of the information (only for patients diagnosed with a malignancy) to be gathered directly from the patient or patient's representative is the detailed residential address with duration of stay in the address (minimum one year ). Plan to obtain this information? (Please select one of the following)

(i) At the time of receiving specimen/slide
(ii) From medical records
(iii)Through concerned clinician
(iv) At the time of issue of report
(v) Other means (Please specify the methodology)

Based on our experience the best time to obtain this information is at the time of issue of the pathology report. Is this feasible in your set-up?

(Please select one of the following)

Yes

6. Approximate Number of Malignant Neoplasms reported per annum by Department of Pathology (Including Histopathology, Haematology, Cytology) (Please select one of the following)

	Less than 300		300-500		500-1000
	1000-2000		2000-3000		More than 3000

7. Computer facilities in Department of Pathology (Please select the box provided)

	Yes	No
(i) Access to Computer for feeding reports
(ii) Whether able to generate printed reports
(iii) Whether able to analyse reports
(iv) Access to Internet / e-mail

8. Would your Institution/department be able to obtain the following or funds for the following items, for use in the project (Please select the box provided)

	Yes	No	Already available
(i) Personal Computer
(ii) Independent Telephone connection
(iii) Internet /e-mail connection
(iv) Funds for contingency / maintenance

9. Approximate funds required per annum (Please select one of the following) *

	Rs 25,000		Rs 50,000
	Rs 75,000		Rs 1.0 lakh

* At Present no funds are available.

10. Continuation of project at end of two years through funds of your institution? (Please select one)

Yes

Already available

11. Any other requirement with justification:


( On submission you have the option to print the filled in form for your records. )

Signature:

Name:

Head of Department of Pathology Head of Institution

Note
A.	The Principal Investigator will be the main corresponding/contact person for all matters including release of funds and be overall in-charge of the project in the respective Institution.
B.	However (Item No 4 in proforma), a person in the department of pathology - preferably a junior faculty member on the permanent role should be identified. This person would be responsible for the day to day working of the project, during the next two years. The person identified should be interested in such work in the project that involves:
	(i)	Completion of identifying information, especially residential status of all malignant neoplasms as and when in the department of pathology.
	(ii)	Completion of Topography and Morphology details including coding of such cases.
	(iii)	Ensuring that the same is correctly entered on to the computer.
	(iv)	Ensuring that the data so entered is regularly transmitted through the net to the Co-ordinating unit.
	(v)	Replying to queries concerning the data transmitted. Appropriate training and guidance will be provided for all of above.
C	Nomination of Co-Principal Investigator is optional
D.	WHO/ICMR does not accept any responsibility for employing persons on the project.