Form 15 Attach 1O - Z4032 CTSU Data Transmittal Form

Attach_1o_z4032_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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Attach_1o_z4032_DTF

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

*STY-Z4032*

Z4032
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: __ __-__ __ __-__ __ __ __

Total # Pages Faxed: _______

(dd-mmm-yyyy)

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.

Please enter the number of pages in each of the visit boxes below
EXAMPLE
FORM

Check if
amended?

CHEST and ABD CT
(On one report)

:

ABD CT



FORM

PreReg

ABD CT
CHEST CT
PFT
OPERATIVE REPORT
PATH and STAPLE LINE
CYTOLOGY (On one report)
PATH REPORT
STAPLE LINE CYTOLOGY
PET
BIOPSY
NOTE TO FILE
OTHER _______________
OTHER _______________
OTHER _______________

M1

M3

M6

M12

M18

M24

M30

M36

4

Visit__________ Pages___

PreReg

DAY
0

M1

M3

M6

M12

M18

M24

M30

M36
















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

Form Version: 02-Nov-2007

Other

Visit__Month 48_ Pages_3_

Check if
amended

CHEST and ABD CT
(On one report)

DAY
0

Other
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Visit__________ Pages___
Visit__________ Pages___
Visit__________ Pages___
Visit__________ Pages___
Visit__________ Pages___
Visit__________ Pages___
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