Form 29 Attach 1CC - CTSU Transfer Form

Attach_1cc_PTTF

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_1cc_PTTF

______________________________________________________________________
Request for Patient Transfer between CTSU Sites and Investigators
Date of Request: ______________

Requested Effective Date of Transfer: ______________

Patient ID#: __________________

Group/Protocol Number: _________________________

MM/DD/YY

MM/DD/YY

Transferring Site/Investigator* Information:
Site Name: _______________________________________________ NCI Code: ___________
Treating Investigator Name: _________________________________ CTEP ID#: __________
Treating Investigator Signature: ___________________________________________________
Receiving Site/Investigator* Information:
Site Name: _______________________________________________ NCI Code: ___________
Credited Cooperative Group (For follow-up credit):
___________________________________________
Treating Investigator Name: _________________________________ CTEP ID#: ___________
Treating Investigator Signature: ___________________________________________________
*By signing this form the receiving site takes responsibility for all outstanding data from the
originating site. Please review the Transfer checklist.
*Completion of this form is required for transfers between investigators located at the same site.
-------------------------------------------Level of responsibility being transferred to receiving site or investigator:

□
□

All
Partial: (explain extent of transfer)_______________________________________________

Contact Person from Receiving Site:
_________________________________________________
Phone #: ____________________ Email Address: ____________________________________
Complete this form and submit to the CTSU Operations Center by e-mail at [email protected] or by
fax to 1-888-691-8039. For more information, contact the CTSU Help Desk at 1-888-823-5923 or
[email protected].

Requests will be reviewed within 5 business days of receipt.
CTSU Use Only:
Receiving site approved for registration:
Receiving Investigator eligible:
Date: _________ Int. ____________
Date: ________ Int.________
Lead Protocol Group Contacted:
Date: _________ Int. _____________

CTSU Data Operations Contacted:
Date: ________ Int. _______

PMB Copied: dt_______ Int._________

Transfer type: ________________

Request for Patient Transfer between CTSU Sites and Investigators
PRS.02.08.e1.docx

Page 1 of 1

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

Attach_1cc_PTTF

Patient Transfer and Physician Update
Checklist
The following information must be provided to CTSU for patient transfers and physician
updates:
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Patient ID
Protocol/Study ID
Date of Request
Transfer Effective Date
Level(s) of responsibility being transferred to the receiving site.
o All
o Partial, explain (For example, if the receiving site is not assuming all the
responsibility for the patient (e.g., follow-up, data management), it should
be explained here.)
Name of transferring institution and its NCI Code
Name of transferring principal investigator and his/her CTEP ID
Name of the receiving institution and its NCI Code
Name of the receiving principal investigator and his/her CTEP ID
Signature of transferring institution treating investigator (if available)
Signature of receiving institution treating investigator
Name, phone number and email address of individual completing the request

The following regulatory requirements must be verified by the CTSU Patient Transfer
Coordinator:
 The receiving site has an active Institutional Review Board (IRB) approval status
for the study
 The receiving principal investigator (physician of record) has an active CTSU
membership
Transferring Site Responsibilities
1) All data clarifications must be resolved prior to the transfer.
2) All outstanding CRFs must be submitted prior to the transfer.
3) Copies of all CRFs and subject records must be submitted to the received site prior to
the transfer.
4) A listing of any outstanding queries or forms that cannot be resolved prior to transfer
must be submitted to the receiving site.
5) Originating sites will be subject to audit for visits up to the point of transfer.

Patient Transfer and Physician Update Checklist
PSP.PRS.02.08.e2.docx

Page 1 of 2

Attach_1cc_PTTF

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

Receiving Site Responsibilities
1) Receiving sites are responsible for all queries upon acceptance of the transfer.
2) Receiving sites are responsible for all delinquent forms upon acceptance of the
transfer.
3) Patients should be reconsented per local institutional and IRB policies.
3) Receiving sites may be subject to audit of cases after the time of subject transfer.
4) For transfers received from a lead Group site, the site must submit the CTSU Patient
Enrollment Form and copies of the enrollment confirmation with the transfer form to
CTSU to establish a subject record.
5) Sites must select a credited Group for follow-up payments and audit.

Patient Transfer and Physician Update Checklist
PSP.PRS.02.08.e2.docx

Page 2 of 2