Form 15 Patient Enrollment Transmittal form

Attachment_A15_ptentf

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

Public reporting burden for this collection of information is estimated to average 10 minutes per response,
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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-xxxx). Do not return the completed form to this address.

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

Attachment_A15_ptentf

CANCER TRIALS SUPPORT UNIT
PATIENT ENROLLMENT TRANSMITTAL FORM
CTSU patient enrollment hours are 9:00 am – 5:30 pm ET – Mon.-Fri.
To enroll a patient:
1) Complete this cover sheet
2) Call the CTSU Help Desk about the incoming enrollment. (1-888-823-5923 or [email protected])
3) Fax cover sheet along with any other protocol-specific forms due at enrollment to the CTSU Patient
Registrar at 1-888-691-8039. ( *For Emergencies call the CTSU Help Desk)

1.

Date:(MM/DD/YYYY)

/

2.

Patient is to be enrolled on:

/ _20

Enrollment Cover sheet plus (

Lead Organization Name and Protocol Number

3.

Enrollment Contact Person:

Phone:

First name

Last name

Fax:
4.

E-mail:

Treating Institution:
Name

5.

Treating Institution’s NCI code:

6.

Treating Physician:

State

CTEP ID:
First name

7.

City

Last name

Indicate Group affiliation to receive enrollment credit:
Cooperative Group name

8.

Date patient signed IRB-approved consent form: (MM/DD/YYY) Date:

9.

Date of HIPAA authorization signed for release of PHI to the CTSU and the protocol lead group:
Date signed (MM/DD/YYYY)

/

/ 20

Exempt (non-USA participant/small business)

ADDITIONAL INFORMATION (Optional)
For expedited shipping please provide your Federal Express Account Name and Number*.
Account Number:
*Available for selected protocols as outlined in the drug shipment information in the protocol. This information must be
completed for each patient enrollment where expedited drug shipment is available.

To be completed by the CTSU Registrar:
Patient ID:
Enrollment Date:

Final_April_2016
Authorized for reproduction by CTSU a service of NCI

Treatment Arm