Form 6 Clinical Brochure

CTEP Branch Support Contracts Forms and Surveys (NCI)

Attachment_A06_clinbroch_102221_Clean

CTSU Request for Clinical Brochure (Attachment A6)

OMB: 0925-0753

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Attachment_A6_clinbroch OMB# 0925-0753

Expiration Date 05/31/2024

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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Shape2 CTSU REQUEST FOR CLINICAL BROCHURE


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________________________________

Date:


Investigator Name and Investigator #:



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Name


Name and phone # of person completing this form:


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Name


PROTOCOL NUMBER

DRUG NAME

NSC NUMBER








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NCI investigator #




( )

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Phone #





Name and email address where document(s) should be sent:


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Name:


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Email Address:

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