attachment_1cc

Attachment_1cc
Attach_1cc_PTTF

OMB#0925-0624
OMB#0925-0624
Expiration Date:
Expiration
Date:12/31/2013
12/31/2013

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 (0925-0624). Do not return the completed form to this address.

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OMB#0925-0624
Expiration Date: 12/31/2013

Attachment_1cc

Request for Patient Transfer (For studies in OPEN and on the CTSU menu; SWOG sites must use the SWOG
online system for SWOG studies; all sites must use the GOG system for GOG studies.)

Date of Request:

Requested Effective Date of Transfer:
MM/DD/YY

MM/DD/YY

Group/Protocol Number:

Patient ID#:

Case Status:

Active Trt

Is the transfer occurring between registration steps? Yes/No

F/up

Transferring Site/Investigator* Information: (Please submit the form to receiving site (if applicable) after
completion of this section.)

Site Name:

CTEP Code:

Treating Investigator Name:

CTEP IID#:

Treating Investigator Signature:

Receiving Site/Investigator* Information:
CTEP Code:

Site Name:

Credited Cooperative Group (For follow-up credit):

Treating Investigator Name:

CTEP IID#:

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:
□ Full: (All responsibility for the patient is transferred to receiving institution)
□ Partial: (Temporary transfer of subject to another site; please indicate the level of responsibility at the receiving site)
____________________________
□ Data Share: (For transfers for studies in Rave, if supported by the LPO; sites may elect to share data. Indicate length of
time required for data sharing.) _________________

Contact Person: ___________________________________________________________
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 3 business days of receipt.
Office Use Only:
Receiving site approved for registration:
Receiving Investigator eligible:
Date:
Int.
Date:
Int.
LPO Authorization: _______________

Request for Patient Transfer

PMB Copied: dt_

Int._

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