Withdraw from Protocol Participation Form

Attach_A03_WD

OMB# 0925-0753
Expiration Date 07/31/2021

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Bethesda, MD 20892-7974, ATTN: PRA (0925-0753). Do not return the completed form to this address.

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OMB# 0925-0753
Expiration Date 07/31/2021

Attach_A3_WD

Submit to the CTSU
Regulatory Office via the
Email, Mail or Regulatory
Fax to: Submission
Portal: www.ctsu.org.

Cancer Trials Support Unit

Cancer Trials Support Unit (CTSU)
ATTN: Coalition of Cancer
Cooperative Groups (CCCG)
Suite1100
1818 Market Street
Philadelphia, PA 19103
FAX: 1-215-569-0206

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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mm d d y y y y

Final_October_2016
July_2018
Authorized by CTSU for local reproduction

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