IASLC Staging Project Financial Support Application

IASLC Staging Project Financial Support Application
Submission Date

MonthDayYear
Date
Institution Information
Institution
Type of Institution
If other, please explain:
Department
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Is the Institution located in a developing country?

YesNo
Department Chief Information
First NameLast Name
Email Address*
Phone Number

Country CodeArea CodePhone Number
IASLC Member?

YesNo
If yes, please provide the membership ID number
Principal Investigator Information
First NameLast Name
Email Address*
Phone Number

Country CodeArea CodePhone Number
IASLC Member?

YesNo
If yes, please provide the membership ID number
Database Information
Type of Database
If other, please explain
Method of Data Entry
How will the data be entered into the database?

Electronic Data Capture (EDC)Batch Upload*
*If data is provided as a batch dataset, but is ultimately found to be incompatible or missing essential data elements, there is no guarantee that reimbursement will be provided.

Please see Policy for additional information
Case Information
Estimated number of cases to be submitted annually
Percentage of non-surgical cases

Please select the approximate percentage of cases that include the following clinical information

	None	0-30%	30-60%	60-90%	90-100%
Clinical TNM
Clinical Tumor Size
Clinical Tumor Size of GGO Component
Pathological TNM
Pathological Tumor Size
Pathological Tumor Size of Non-Invasive Component
Number of Metastatic Node and Station
Histological Type

Please select the approximate percentage of cases that include the following molecular analysis

Please select the approximate percentage of cases that include the following patient follow-up information

	None	0-30%	30-60%	60-90%	90-100%
Recurrence Status
Survival Status

Budget
What is the total amount you are requesting (USD)*
Purpose for funds*

Start-upData Entry
Please submit a 1 page Needs Statement*
Please submit an itemized budget*

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Institution Information