Form 6 Clinical Brochure

Attachment_A6_clinbroch

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

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 (0925-0753). Do not return the completed form to this address.

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Attachment_A6_clinbroch

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

CTSU REQUEST FOR CLINICAL BROCHURE
To request a copy of a Clinical Brochure for an IND, please complete the information below and upload the form to
the Regulatory Submission Portal. Select the Membership/Supply document type. 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 #:
NCI investigator #

Name
Name and phone # of person completing this form:

(
)
Phone #

Name

PROTOCOL NUMBER

DRUG NAME

Name and address (express mail) where document(s) should be sent:
Name:
Address:
City, State, Zip:
Phone: ( ______)
Email Address:
CTSU Internal Reminders
Verify NCI Investigator number
Verify investigator Status is active
Verify investigator is active on participating roster
Set packet to complete

Final July 2018
Authorized by CTSU for local reproduction

NSC NUMBER