Ladera Ranch Community Health Registry - Reporting Form
Ladera Health Watch is collecting information to better understand local patterns of cancer, autoimmunity, and related conditions. Your responses will help identify possible environmental, geographic, or related factors affecting our community.

Please allow 5-10 minutes per person. Submit one form for each affected household member; after you submit, you will see a "Submit another response" link to report the next person. Our data is only as good as you are thorough.

By submitting this form, you acknowledge that your information will be used for local health analysis and advocacy and may be aggregated and shared with public health experts and agencies.

You may request removal of your information at any time. Participation is voluntary.

To update or remove your response, please contact laderahealthwatch@gmail.com
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How your information is protected



What we collect: your contact information, and details about diagnosis, residence history, schools, activities, and home environment for the person being reported.

Who can see it: raw responses are accessible to two designated volunteers only. Everyone else working on this effort, including analysis, mapping, and outreach, works from a version with names, email addresses, phone numbers, and street addresses removed.

How it's shared: only in aggregate, non-identifying form. The California Cancer Registry has asked us for aggregate information only: number of cases, cancer type, approximate year of diagnosis, age or age range at diagnosis, and length of time living in Ladera Ranch. No names or identifying information are being requested by, or will be shared with, the Registry or any other agency.

Your control: participation is voluntary. You can request removal of your information at any time by emailing laderahealthwatch@gmail.com, and we will delete it.

What this is: a volunteer effort by neighbors. We are not a public health agency, medical provider, or law firm.
I consent to the collection of this information. *
Who is completing this form?
Clear selection
Your first name
Your last name
Email
We collect your email so we can follow up on your report and reach you if we learn something that may be helpful or relevant to you. Use the same email for each household member you report so we can group your household together.
Phone
How many people in your household are you reporting in total (including this one)?
May we contact you if more information is needed?
Clear selection
Optional: check any that apply
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