Form 17 Attach 1Q - Z1041 CTSU Data Transmittal Form

Attach_1q_Z1041_DTF

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

Public reporting burden for this collection of information is estimated to vary from 5 to 10 minutes per response,
including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data
needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and
a person is not required to respond to, a collection of information unless it displays a currently valid OMB
control number. Send comments regarding this burden estimate or any other aspect of this collection of information,
including suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974,
Bethesda, MD 20892-7974, ATTN: PRA (0925-xxxx). Do not return the completed form to this address.

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

Attach_1q_Z1041_DTF

Z1041
CTSU DATA TRANSMITTAL FORM
Please FAX to: 1-301-545-0406

Call 1-888-823-5923 if you are experiencing difficulty faxing
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Record only one patient and protocol per transmittal sheet
Ensure Patient ID and Protocol ID are recorded on each page of each item included
Ensure pages are in proper sequence (2-sided forms must be copied by site before faxing)
Do not fax more than 50 pages in one submission
Submit updated data with a new transmittal and new date
Ensure updates to forms are initialed and dated

Date: __ __-__ __ __-__ __ __ __
(dd-mmm-yyyy)

Total # Pages Faxed: _______

Patient ID#: __ __ __ __ __

(including transmittal)

Site Name: ________________________________________________________

NCI Site Code: __ __ __ __ __
(Example TX001)

Site Address: _________________________________________________________________________________
Completed By: ___________________________________________ Phone # ____________________________
Email address: _______________________________________________________________________________
Contact Information. Will be used if CTSU has questions or if data submission needs to be re-submitted with corrective action.

Report
#

Check only one report per box

# pgs in
report

Check only one visit per box

1

O: Lab Work O:ECHO O:MUGA
O: Mammogram
O: Ultrasound
O: Operative report
O: Pathology
O: Memo/ Note to File O: Other __________

O: Baseline
O: Surgery
O: Mo12 FU
O: Mo48 FU

O: Interim
O: Pre-Op
O:Mo3 Cycle O: Mo6 Cycle
O: Mo24 FU O: Mo36 FU
O: Other _______________

2

O: Lab Work O:ECHO O:MUGA
O: Mammogram
O: Ultrasound
O: Operative report
O: Pathology
O: Memo/ Note to File O: Other __________

O: Baseline
O: Surgery
O: Mo12 FU
O: Mo48 FU

O: Interim
O: Pre-Op
O:Mo3 Cycle O: Mo6 Cycle
O: Mo24 FU O: Mo36 FU
O: Other _______________

3

O: Lab Work O:ECHO O:MUGA
O: Mammogram
O: Ultrasound
O: Operative report
O: Pathology
O: Memo/ Note to File O: Other __________

O: Baseline
O: Surgery
O: Mo12 FU
O: Mo48 FU

O: Interim
O: Pre-Op
O:Mo3 Cycle O: Mo6 Cycle
O: Mo24 FU O: Mo36 FU
O: Other _______________

4

O: Lab Work O:ECHO O:MUGA
O: Mammogram
O: Ultrasound
O: Operative report
O: Pathology
O: Memo/ Note to File O: Other __________

O: Baseline
O: Surgery
O: Mo12 FU
O: Mo48 FU

O: Interim
O: Pre-Op
O:Mo3 Cycle O: Mo6 Cycle
O: Mo24 FU O: Mo36 FU
O: Other _______________

5

O: Lab Work O:ECHO O:MUGA
O: Mammogram
O: Ultrasound
O: Operative report
O: Pathology
O: Memo/ Note to File O: Other __________

O: Baseline
O: Surgery
O: Mo12 FU
O: Mo48 FU

O: Interim
O: Pre-Op
O:Mo3 Cycle O: Mo6 Cycle
O: Mo24 FU O: Mo36 FU
O: Other _______________

Contact Information: Westat, CTSU Data Operations, 5615 Kirby Drive, Suite 710, Houston TX, 77005

Check if
Changed
Data