Form 19 CTSU Request for Clinical Brochure

Cancer Trials Support Unit (CTSU) Public Use Forms and Customer Satisfaction Surveys (NCI)

attachment_1s_clinbroch

Attach 1S - CTSU Request for Clinical Brochure

OMB: 0925-0624

Document [pdf]
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Attachment_1s_clinbroch
Attach_1ee_CTSUIB

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

Public reporting burden for this collection of information is estimated to vary from 10 minutes per response,
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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

CTSU

Attachment_1s_clinbroch
Attach_1ee_CTSUIB

REQUEST FOR CLINICAL BROCHURE
To request a copy of a Clinical Brochure for an IND, please complete the information below and fax this form the CTSU
Data Center at 1-888-691-8039. Following review and approval of this application, a copy of the brochure will be mailed
to the address you provide below. Please allow 7-10 business days for processing and mailing of supply requests.

Date: ________________________________
Investigator Name and Investigator #:
______________________________________
Name

___________________
NCI investigator #

Name and phone # of person completing this form:
_______________________________________
Name

(______)________________
phone #

Brochures requested:
PROTOCOL NUMBER

DRUG NAME

NSC NUMBER

l

Name and address (express mail) where document(s) should be sent:
Name: __________________________________________________________________________
Address: ________________________________________________________________________
________________________________________________________________________
City, State, Zip:__________________________/______________________/_________________
Phone: (______)__________________________________________________________________
Email Address: __________________________________________________________________

NCI Investigator number verified?
PMB investigator status is active?
Active on at least one Group Roster?

Yes
Yes
Yes

No
No
No

CTSU use only

Verified by
______________________
Date
_____________________________
Shipment date: _____________________________
Comment:________________________________________________________________________________________
Comment: ________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________

CTSU_IB_v4_July2013
CTSU_IB_v.3_03
authorized by CTSU for local reproduction


File Typeapplication/pdf
File TitleMicrosoft Word - CTSU_inv_brochure_request_v22 3-26-03.rtf
Authoryoung_l
File Modified2013-07-31
File Created2003-03-27

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