Form 31 Attach 1EE - CTSU Request for Clinical Brochure

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

attach_1ee_ctsuib

Attach 1EE - CTSU Request for Clinical Brochure

OMB: 0925-0624

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Attach_1ee_CTSUIB

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

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Attach_1ee_CTSUIB

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

CTSU
REQUEST FOR CLINICAL BROCHURE

To request a copy of a Clinical Brochure for an IND, please complete the information below and fax this form the CTSU
Data Center at 1-888-691-8039. Following review and approval of this application, a copy of the brochure will be mailed
to the address you provide below. Please allow 7-10 business days for processing and mailing of supply requests.

Date: ________________________________
Investigator Name and Investigator #:
______________________________________
Name

___________________
NCI investigator #

Name and phone # of person completing this form:
_______________________________________
Name

(______)________________
phone #

Brochures requested:
PROTOCOL NUMBER

DRUG NAME

NSC NUMBER

l

Name and address (express mail) where document(s) should be sent:
Name: __________________________________________________________________________
Address: ________________________________________________________________________
________________________________________________________________________
City, State, Zip:__________________________/______________________/_________________
Phone: (______)__________________________________________________________________

NCI Investigator number verified?
PMB investigator status is active?
Active on at least one Group Roster?

Yes
Yes
Yes

No
No
No

CTSU use only

Verified by
______________________
Date
_____________________________
Shipment date: _____________________________
Comment:________________________________________________________________________________________
________________________________________________________________________________________________

CTSU_IB_v.3_03
authorized by CTSU for local reproduction


File Typeapplication/pdf
File TitleMicrosoft Word - CTSU_inv_brochure_request_v22 3-26-03.rtf
Authoryoung_l
File Modified2010-10-12
File Created2003-03-27

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