Form 3 Withdrawl form

Attach_A03_WD

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

Public reporting burden for this collection of information is estimated to vary from 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_A3_WD

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

Cancer Trials Support Unit
Optional form 1
Withdraw from Protocol Participation

[email protected]

Institution Name (List all institutions permanently closing this study)

NCI Institution Code : (ALXXX)

Protocol Title: (Shortened version acceptable)

Protocol Number:

Rationale for Study Closure: (Select the answer that best describes the closure)
1) No subjects were accrued at the institution(s) listed above, and the
protocol is now closed to accrual by the sponsoring organization.
2) No subjects were accrued at the institution(s) listed above, and the
study has been closed with the local IRB with no anticipation of future
accrual (If the protocol is re-opened at a later date the site must submit
an initial approval).
3) All subjects accrued at local institutions have completed treatment
and follow-up and no further accruals are anticipated at the institution(s)
listed above.
4) IRB/Ethics board responsibilities for the protocol listed above are
being transferred to another IRB. Review responsibilities at IRB #
are being transferred to IRB#
(Please
note that initial review of this protocol from the new IRB must be
submitted to the CTSU. Submission of this form only documents
withdraw of the approval from the originating IRB.)

Date of IRB/Ethics Board Action:

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The institutional staff signing below certifies that the information provided above is correct.
Name of Signatory:
Name of approving Organization:
Title of Signatory:

Signature:

Phone
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Date:
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Final_October_2016
Authorized by CTSU for local reproduction

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