Form 3 Attach 1C- CTSU Acknowledgement Form

Cancer Trials Support Unit (CTSU) Public Use Forms and Customer Satisfaction Surveys (NCI)

attach_1c_ctsuac

Attach 1C- CTSU Acknowledgement Form

OMB: 0925-0624

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Attach_1c_CTSUAC

OMB#0925-xxxx
Expiration Date: xx/xx/xxxx

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OMB#0925-xxxx
Expiration Date: xx/xx/xxxx

Attach_1c_CTSUAC

Cancer Trials Support Unit

Acknowledgment Form
(for sites utilizing the NCI CIRB)

Email, Mail or Fax to:
Cancer Trials Support Unit (CTSU)
ATTN: Coalition of Cancer Cooperative Groups (CCCG)
Suite1100
1818 Market Street
Philadelphia, PA 19103
FAX: 1-215-569-0206
[email protected]

This form is NOT an IRB approval document. The form does NOT require an IRB approval nor IRB signature,
but may be completed by the local site research personnel. By signing this form, you are informing the CTSU
that each site listed below is currently covered by the NCI CIRB and that the CTSU should enter either a
continuing renewal or amendment approval for the site(s) & protocol identified.
1) Protocol #:

3) Institution Name (List all institutions covered by IRB approval
that will conduct this study. Attach complete list if necessary.)

2) Protocol Version Date (Required for Amendments Only):
_____/___/__________
m m d d y y y y
4) NCI
5 & 5a) OHRP Federalwide Assurance Number
Institution
Code
FWA
FWA Expiration Date
(mm/dd/yyyy)

Ex: University of State

ALXXX

6) Principal Investigator:

7) NCI Investigator #:

8) Approval Type:

9) OHRP IRB Registration Number (for the NCI CIRB):

Amendment

FWA00000123

03/01/2006

IRB00000781

Renewal

10) Comments:

The person signing below certifies that the information provided above is correct.
Questions #1 through #9 must be completed for this form to be accepted.
11) Name of Person Signing Form:

12) Site Role:

13) Title (if applicable):

14) Phone Number:
(_______) |________| - |____________|

15) Signature:

16) Date:
_____/______/_________
mm d d y y y y

Final_June2009
Authorized for reproduction by CTSU a service of NCI


File Typeapplication/pdf
File TitleCancer Trials Support Unit
File Modified2010-06-01
File Created2009-06-22

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