North San Fernando Valley Cancer Cases

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* 1. What type of cancer was the diagnosis?

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* 2. Gender?

Male

Female

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* 3. Age at time of diagnosis?

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* 4. What was the year of diagnosis?

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* 5. What was the Zip Code of residence during the time of diagnosis?

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* 6. Who diagnosed you? Name a facility.

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* 7. Provide contact phone number (OPTIONAL)