Form 31 Attach 1EE - CTSU Request for Clinical Brochure

Attach_1ee_CTSUIB

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

Public reporting burden for this collection of information is estimated to vary from 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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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