Form 1 CTSU IRB/Regulatory Approval Transmittal Form

Attach_1a_CTSUTS
Attachment_1a_IRBTRANS

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

Public reporting burden for this collection of information is estimated to average 2 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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CTSU Transmittal Sheet
Total Pages Sent (______)

Date Sent:

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SEND TO: CTSU CENTRAL REGULATORY OFFICE
ATTN: Coalition of Cancer Cooperative Groups (CCCG)
Suite 1100
1818 Market Street
Philadelphia, PA 19103
FAX: 1-215-569-0206

[email protected]
Packet Type:
enrolled
next
three
days)
Urgent (patient(s)
(patient to to
bebe
enrolled
in in
thethe
next
three
days)

Normal

Attn: ________________________
Applicable NCI Institution Codes: ________________________________
Applicable Protocol Numbers: ___________________________________
Institutional Principal Investigator (if applicable):___________________

Protocol Contact at Site:
First Name

Last Name

Phone

e-mail

Comments:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

Final_July2013
Authorized by CTSU for local reproduction