Form 3 CTSU Acknowledgement Form

Attach_1c_CTSUAC

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

Public reporting burden for this collection of information is estimated to average 5 minutes per response,
including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data
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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

Attach_1c_CTSUAC

Cancer Trials Support Unit

Acknowledgment Form
(for sites utilizing the NCI CIRB)

Email, Mail or Fax to:
Cancer Trials Support Unit (CTSU)
ATTN: Coalition of Cancer Cooperative Groups (CCCG)
Suite1100
1818 Market Street
Philadelphia, PA 19103
FAX: 1-215-569-0206
[email protected]

This form is NOT an IRB approval document. The form does NOT require an IRB approval nor IRB signature,
but may be completed by the local site research personnel. By signing this form, you are informing the CTSU
that each site listed below is currently covered by the NCI CIRB and that the CTSU should enter either a
continuing renewal or amendment approval for the site(s) & protocol identified.
1) Protocol #:

3) Institution Name (List all institutions covered by IRB approval
that will conduct this study. Attach complete list if necessary.)

2) Protocol Version Date (Required for Amendments Only):
_____/___/__________
m m d d y y y y
4) NCI
5 & 5a) OHRP Federalwide Assurance Number
Institution
Code
FWA
FWA Expiration Date
(mm/dd/yyyy)

Ex: University of State

ALXXX

6) Principal Investigator:

7) NCI Investigator #:

8) Approval Type:

9) OHRP IRB Registration Number (for the NCI CIRB):

Amendment

Renewal

FWA00000123

03/01/2006

Adult-Late Phase Emphasis Board: IRB00000781
Adult-Early Phase Emphasis Board: IRB00009430

Pediatric Board: IRB00004296

IRB00000781

10) Comments:

The person signing below certifies that the information provided above is correct.
Questions #1 through #9 must be completed for this form to be accepted.
11) Name of Person Signing Form:

12) Site Role:

13) Title (if applicable):

14) Phone Number:
(_______) |________| - |____________|

15) Signature:

16) Date:
_____/______/_________
mm d d y y y y

Final_July2013
Final_June2009
Authorized for reproduction by CTSU a service of NCI