Form 28 Attach 1BB - CTSU P2C Enrollment Transmittal Form

Attach_1bb_p2c_PETF

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_1bb_p2c_PETF

CANCER TRIALS SUPPORT UNIT
P2C PATIENT ENROLLMENT TRANSMITTAL FORM
CTSU patient registrars process enrollments between 9:00 AM and 5:00 PM ET, Mon. - Fri. Enrollments
received after 5pm will be processed the next business day unless the CTSU registrars office is notified via the emergency
number of a time of need enrollment. Prior to enrollment, please refer to the enrollment documents on the CTSU members’
web site as some protocols have limited enrollment hours.
To enroll a patient:
1) Complete this cover sheet
2) Call 1-888-462-3009 and notify CTSU Patient Registrar of incoming enrollment.
3) Fax cover sheet along with any other protocol-specific forms due at enrollment to the CTSU Patient
Registrar at 1-888-691-8039. *For Emergencies call 301-704-2376
1.

Date:(MM/DD/YYYY) _______________________

2.

Patient is to be enrolled on:

3.

Enrollment Contact Person:________________________________Phone: _______________

Enrollment Cover sheet plus (

___________________________________________________
Lead Consortium and NCI Protocol Number (e.g. Mayo P2C #8233)

First name

Last name

Fax: _____________________________

4.

E-mail: ____________________________________

Treating Institution: __________________________________________________________________
Name

City

5.

Treating Institution’s NCI code (e.g. TX001):

6.

Treating MD: ________________________________________ CTEP ID:
First name

7.

) page(s)

State

Last name

Name of N01 consortium to receive enrollment credit:
Mayo P2C (MPC)

Ohio State University P2C (OSU-CSM)

M.D. Anderson P2C (MDAC)

Princess Margaret Hospital P2C (PMHC)

Memorial Sloan Kettering P2C (MSKC)

U. of California-Davis P2C (UCD-CSM)

H.Lee Moffitt P2C (HLMCC-CSM)

U. of Chicago P2C (UCC)

Montefiore Medical Center P2C (MMC)
8.

Provide any specimen tracking ID or ancillary study ID that has previously been assigned to this subject
for this trial or a related ancillary study. __________________ID ____________________ ID Source

9.
10.

Date patient informed consent signed:__________________
(MM / DD / YYYY)
Date HIPAA authorization signed (if applicable):______________
(MM / DD / YYYY)

To be completed by the CTSU Registrar:
Accrual/Tracking # ________________________________ Patient ID _____________________________