NAACCR Standards

Request for Change Form

Date of request: 01/20/2017

*For a concept level proposal, all fields with asterisks must be completed. For all other proposals, complete all fields. Requests for multiple data items may be submitted on one form at the concept level; however, each data item will need a separate form in order to include the description, rationale, codes, etc. specific to each data item.

* = required






*Contact person for proposal:


*Proposed effective date:
(Please enter proper date format MM/DD/YYYY ex. '12/25/2014')