THE ELDORET CANCER REGISTRY
CANCER NOTIFICATION FORM
(First name(s)
……….……………………
..................
......
Given name
…….……………………
............................
Surname (Family name)
...................................................................
I.D. Number:
...................................
Date of birth
Age:
Sex:
(1=male,
2=female,
9=NK)
Place of birth ……………………………………………………………………………………………………………………..
Usual residence address:
…………………………………………………………………………………………………………...
Concurrent illness……………………………………………………
(1=Positive, 2=Negative, 9=NK)
Next of Kin: Father/Mother/Husband/Wife/Son/Daughter …………………………………………………………….
Patients Tele. number:
Tel No. Next of Kin
Ethnic group:
Death Certificate No.
2. FOLLOW UP
Date of last contact (dd/mm/yyyy):
Status at last contact (1=Alive, 2=Dead, 9=NK)
____________
Hospice No.
_______________________________________
Cause of death
(1= this cancer, 2= 0ther cause, 9= NK)
Patients Age ……………………… Address Code ……………………………………………………………………………….……….
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