Cancer Inquiry Intake Form

This intake form is designed to assist your State, Tribal, Local, or Territorial (STLT) health department in collecting standardized information when you receive an inquiry about unusual patterns of cancer and environmental concerns. For further information, please reference CDC/ATSDR's "Guidelines for Examining Unusual Patterns of Cancer and Environmental Concerns."

If you have questions please email us: nmtr-info@salud.unm.edu

Form Approved
OMB No. 0920-0879
Exp. Date 01/31/2024

Tracking Information

What date was the inquiry made?

How did the inquirer initially make contact? Phone Email In-person Mail NM DOH On Call Other

Details for how did the inquirer initially make contact

Staff Member

What staff member answered the initial inquiry? NMTR Staff NM DOH Staff CDC Staff

Staff Member's Name

Staff Member's Email

Inquirer's Information

What is the inquirer's title?

Inquirer's First Name

Inquirer's Last Name

Inquirer's Mailing Address

Mailing Address

City, town, village, or township

ZIP code

What is the inquirer's preferred method of communication?

Other method of communication

Future Communication

For future communication, what day works best for the inquirer?

What day works best for the inquirer?

Insurance

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Insurance Approve Deny

Reason for Denial

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Payment

Payment Type Will Pay On Site Will Pay Online Paid