Download:
pdf |
pdfAttachment 1: CTSU Standard Forms/Surveys List with Burden and Cost Calculations
Attach Section/Form or Survey
No.
Title
Use Metrics/
Estimated
month - # Time for site to
Respond
complete
Estimated
burden
(minutes/
hours)
Frequency Total Annual
of
Usage/Annual
Response Burden Hours
Annual
Cost/Item
($27.20)
Regulatory/Roster
1a
CTSU IRB/Regulatory
Approval Transmittal Form
9,000
2 minutes
0.03
12.00
3,600
97,920.00
1b
CTSU IRB Certification Form
8,500
10 minutes
0.17
12.00
17,000
462,400.00
1c
CTSU Acknowledgement
Form
500
5 minutes
0.08
12.00
500
13,600.00
1d
Optional Form 1 - Withdrawal
from Protocol Participation
Form
50
5 minutes
0.08
12.00
50
1,360.00
Roster Forms
1e
CTSU Roster Update Form
50
2-4 minutes
0.07
12.00
40
1,088.00
1f
CTSU Radiation Therapy
Facilities Inventory Form
20
30 minutes
0.50
12.00
120
3,264.00
11
5-10 minutes
0.17
12.00
22
598.40
3
20 minutes
0.33
12.00
12
326.40
100
5-10 minutes
0.17
12.00
200
5,440.00
1000
5-10 minutes
0.17
12.00
2,000
54,400.00
75
5-10 minutes
0.17
12.00
150
4,080.00
2100
5-10 minutes
0.17
12.00
4,200
114,240.00
650
15-20 minutes
0.33
12.00
2,600
70,720.00
Drug shipment
CTSU IBCSG Drug
1g Accountability Form
1h
CTSU IBCSG Transfer of
Investigational Agent Form
Data Management
1i
Site Initiated Data Update
Form (generic)
1j
N0147 CTSU Data
Transmittal Form
1k
Site Intimated Data Update
Form (DUF), Protocol:
NCCTG N0147*
1l
TAILORX/PACCT 1 CTSU
Data Transmittal Form
1m
Data Clarification Form
1n
Unsolicited Data Modification
Form (UDM),
Protocol:TAILORx/PACCT1
75
5-10 minutes
0.17
12.00
150
4,080.00
1o
Z4032 CTSU Data
Transmittal Form
50
5-10 minutes
0.17
12.00
100
2,720.00
Page 1
10/20/2010
Attachment 1: CTSU Standard Forms/Surveys List with Burden and Cost Calculations
Attach Section/Form or Survey
No.
Title
Use Metrics/
Estimated
month - # Time for site to
Respond
complete
Estimated
burden
(minutes/
hours)
Frequency Total Annual
of
Usage/Annual
Response Burden Hours
Annual
Cost/Item
($27.20)
1p
Z1031 CTSU Data
Transmittal Form
50
5-10 minutes
0.17
12.00
100
2,720.00
1q
Z1041 CTSU Data
Transmittal Form
50
5-10 minutes
0.17
12.00
100
2,720.00
1r
Z6051 CTSU Data
Transmittal Form
75
5-10 minutes
0.17
12.00
150
4,080.00
1s
RTOG 0834 CTSU Data
Transmittal Form*
60
5-10 minutes
0.17
12.00
120
3,264.00
1t
CTSU 7868 Data Transmittal
Form
50
5-10 minutes
0.17
12.00
100
2,720.00
1u
Site Initiated Data Update
Form, protocol 7868
10
5-10 minutes
0.17
12.00
20
544.00
1v
MC0845(8233) CTSU Data
Transmittal*
50
5-10 minutes
0.17
12.00
100
2,720.00
1w
8121 CTSU Data Transmittal
Form*
100
5-10 minutes
0.17
12.00
200
5,440.00
1x
Site Initiated Data Update
Form, Protocol 8121
10
5-10 minutes
0.17
12.00
20
544.00
50
5-10 minutes
0.17
12.00
100
2,720.00
5
5-10 minutes
0.17
12.00
10
272
600
5-10 minutes
0.17
12.00
1,200
32,640.00
USMCI 8214/Z6091: CTSU
Data Transmittal
1y
*In Development
1z
USMCI 8214/Z6091
Crossover Request/Checklist
Transmittal Form
Patient Enrollment
1aa
CTSU Patient Enrollment
Transmittal Form
1bb
CTSU P2C Enrollment
Transmittal Form
30
5-10 minutes
0.17
12.00
60
1,632.00
1cc
CTSU Transfer Form
40
5-10 minutes
0.17
12.00
80
2,176.00
Administrative
1dd
CTSU System Account
Request Form
50
15-20 minutes
0.33
12.00
200
5,440.00
1ee
CTSU Request for Clinical
Brochure
35
10 minutes
0.17
12.00
70
1,904.00
Page 2
10/20/2010
Attachment 1: CTSU Standard Forms/Surveys List with Burden and Cost Calculations
Attach Section/Form or Survey
No.
Title
1ff
1gg
Use Metrics/
Estimated
month - # Time for site to
Respond
complete
CTSU Supply Request Form
CTSU Generic Data
Transmittal Form
Estimated
burden
(minutes/
hours)
Frequency Total Annual
of
Usage/Annual
Response Burden Hours
Annual
Cost/Item
($27.20)
130
5-10 minutes
0.17
12.00
260
7,072.00
500
5-10 minutes
0.17
12.00
1000.00
27200.00
Surveys/Web Forms
2
CTSU Web Site Customer
Satisfaction Survey
250
10-15 minutes
0.2500
1.00
63
1,700.00
3
CTSU Helpdesk Customer
Satisfaction Survey
300
10-15 minutes
0.2500
1.00
75
2,040.00
4
CTSU OPEN Survey
120
10-15 minutes
0.2500
1.00
30
816.00
34,802
946,600.80
104,404.50
2,839,802.40
Annual Totals
21,770
Total for 3 year Approval Period
Page 3
10/20/2010
| File Type | application/pdf |
| File Title | attach_1_form-survey list_10-18-2010.xls |
| Author | horovitchkellv |
| File Modified | 2010-10-20 |
| File Created | 2010-10-20 |