New Jersey Department of Health

Cancer Epidemiology Services

PO Box 369

Trenton, NJ 08625-0369	REQUEST FOR

LEVEL A – AGGREGATE DATA
* Required Fields

*First Name:	*Last Name:
Title:
Organization:
*Street Address:
*City, State, Zip:
*Telephone:	Fax:	Email:
*Please describe the purpose for this request:
*What will you

use this data for?	Report	Research (general)	Media

Presentation	Research (project with NJSCR)

Personal Knowledge	Other: _________________________
Please specify the data you are requesting:
Cancer Incidence Cancer Mortality Other Statistic (specify):
Region:	All NJ and/or Selected Counties (specify):
Diagnosis Year(s):
Cancer Site(s):
Ages:	All Ages and/or Specific Age Group(s) (specify):
Sex:	Race:	Ethnicity:
Other Data (Histology, Stage, etc.):

CES-4

NOV 15

CES-4, Form A, Request for Non-Published, Non-Sensitive DAta

CES-4, Form A, request for non-published, non-sensitive data, cancer epidemiology,

ewhite

2015-10-27

NJDOH