1.Please select the primary use for your Web Plus account:

Cancer ReportingResearch & Data RequestsOther

2.Individual User Information

First Name:

Last Name:

Position / Title:

Email Address:

*Phone Number:

*Please enter your phone number, including area code, formatted xxx-xxx-xxxx. It is important to have your phone number correct on this form as call backs are part of the password reset procedure.

3.Institution / Organization Information

Institution / Organization Name:

Street Address:

Mailing Address:

City:

State:

ZIP:

4.Supervisory Contact / Responsible Party (Institution / Organization)

Supervisor / Manager / PI / Department Chair:

Title / Position:

Email Address:

Phone Number:

5.FOR CANCER REPORTERS ONLY

Texas Cancer Registry ID # (Facility ID #):

*Health Service Region (if in Texas):

*If you do not know which Health Service Region (also referred to as Public Health Region) you are located, you may look it up by county at the following link: https://www.dshs.texas.gov/chs/info/info_txco.shtm#txcotable  

6.FOR RESEARCHERS ONLY

Texas Cancer Registry Data Request #:

DSHS IRB Approval #:

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