Cancer Registry Data Request Form

Please click here to download and fill the Data Request Agreement Form; you will be required to upload the completed form at the end of this process. You could also complete the e-form below. 

AGREEMENT BETWEEN CANCER REGISTRY DATA REQUESTOR,

CANCER REGISTRIES & NIGERIAN NATIONAL SYSTEM OF CANCER REGISTRIES


Name of Data Requestor:

Name of Cancer Registry involved:

Date of Agreement:


This Agreement is entered into on the specified date (“Effective Date”), by you (“Data Requestor”) and between the above-named registry (“Cancer Registry”) and Nigerian National System of Cancer Registries (NSCR).

1. Purpose for the data collected

Data collected will only be used for the purpose specified in the request form. Any
deviation from the specified purpose will lead to a public disclosure and a request will
be made directly to the journal requesting retraction of any article, abstract, papers,
books or any other publication or use resulting from the data.

2. Acknowledgement

When unanalysed data from cancer registries are provided in response to your request,
the cancer registry director shall be a co-author in any publication that utilizes the data.

If the data requested for is analyzed and derived data from the National System of
Cancer Registries, then the Cancer Control Focal person in the Federal Ministry of
Health and scientific staff of the National System of Cancer Registries shall be coauthors.

If researchers use National System of Cancer Registries or individual cancer registries
data that is already in the public domain, e.g. data published in a book, journal articles
or website of NSCR, the authors shall reference the source of the materials in the
standard fashion.

3. Outcome of Use of Registry Data

Copies of articles, abstracts, presentations, papers or books publication resulting from
the provided registry data should be sent to NSCR and the Directors of Cancer
Registries that provided data for the study.

4. Modification or Amendment

No amendment, change or modification of this agreement shall be valid unless in
writing signed by the parties hereto.


I attest that this agreement has been read and will be strictly adhered to:

Name (Data Requestor):

Address:

Signature:

Date:

 

Section A – Data Requestor Details

Your Full Name:

Name of your Institution:

Your Contact Address:

Your Institutional Email Address:

Your Phone Number:

 

Section B – Cancer Information

Cancer site:

Format of cancer data requested:

Cancer Registry(ies) Data Requested: (You can do multiple select by holding down CTRL key and clicking on your choices)

Period of time:

From:

To:

 

Section C – Purpose of Request

Data request rationale/purpose for which data will be used:

Upload the Data Sharing Agreement Form