15 patient Enrollment Transmittal Form

Attachment_A15_ptentf

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

Public reporting burden for this collection of information is estimated to average 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 208927974, ATTN: PRA (0925-0753). Do not return the completed form to this address.

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Final July 2018
Authorized by CTSU for local reproduction

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

Attachment_A15_ptentf

CANCER TRIALS SUPPORTUNIT
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) Upload the form to the Regulatory Submission Portal and select the Enrollment/Transfer document type.
(*For Emergencies call the CTSU Help Desk.)
3) Call the CTSU Help Desk with any questions. (1-888-823-5923 or [email protected])
1.

Date:(MM/DD/YYYY)

/

2.

Patient is to be enrolledon:

3.

Enrollment Contact Person:
Fax:

/20______

Enrollment Cover sheet plus( )

Lead Organization Name and Protocol Number
First name

4.

TreatingInstitution:

5.

Treating Institution’s NCI code:

6.

Treating Physician:

7.

Indicate organizationto receive enrollment credit:

Phone:

Last name
E-mail:

Name

First name

City

Last name

State

CTEP ID:

Organization name

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.

Final July 2018
Authorized by CTSU for local reproduction