Lung Cancer Study

Participation Information Form

All information provided will be kept confidential. This study complies with all HIPAA regulations.

Name
Street Address
City
State
Zip Code
Phone Number
E-Mail Address
I prefer to be contacted by	Telephone E-mail
Best time to contact	AM PM
Age
Race
The following describes me (please check all that apply):
	I have/had Lung Cancer
	I have/had family members with Lung Cancer
	The following family members have/had Lung Cancer (check all that apply):
	Grandfather/Grandmother
	Father/Mother
	Brother/Sister (No. of affected siblings )
	Nephew/Niece
	Uncle/Aunt
	Cousin
	Other (Relation:)

Thank you for your interest in the Lung Cancer Study.