Form 15 CTSU Patient Enrollment Transmittal Form

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OMB#0925-0624
Expiration Date: 12/31/2013

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OMB#0925-0624
Expiration Date: 12/31/2013

Attachment_1o_ptentf
Attach_1aa_PTENTF

CANCER TRIALS SUPPORT UNIT
PATIENT ENROLLMENT TRANSMITTAL FORM
CTSU patient enrollment hours are 9:00 am – 5:30 pm ET – Mon.-Fri. (Prior to enrollment, please refer to the
enrollment documents on the CTSU web site as some protocols have limited enrollment hours. Enrollments received after
5:00 pm will be processed the next day unless the CTSU registrar is notified via the emergency number of a time of need
enrollment.)
To enroll a patient:
1) Complete this cover sheet
2) Call 1-888-462-3009 and notify CTSU Patient Registrar of incoming enrollment.
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 301-704-2376
1.

Date:(MM/DD/YYYY)

2.

Patient is to be enrolled on:

______ / ______ / _20_____

Enrollment Cover sheet plus (

) page(s)

___________________________________________
Cooperative Group Name and Protocol Number

3.

Enrollment Contact Person:________________________________Phone: _______________
First name

Last name

Fax: _____________________________
4.

E-mail: ____________________________________

Treating Institution: __________________________________________________________________
Name

City

5.

Treating Institution’s NCI code:

6.

Treating Physician: _________________________________ CTEP ID:
First name

7.

State

Last name

Indicate Cooperative Group affiliation to receive enrollment credit: ______________________________
Cooperative Group name

8.

Date patient signed IRB-approved consent form: (MM/DD/YYY) Date:______ / ______ / 20

9.

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

10.

Exempt (non-USA participant/small business)

Has patient ever been enrolled on any other Cooperative Group trial?

Y

N

If yes, provide Group name and Protocol number __________________________________
11.

Provide any specimen tracking ID or ancillary study ID that has previously been assigned to this subject
for this trial or a related ancillary study. __________________ID ____________________ ID Source
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: ___________ Treatment Arm____________

Final_Version 4/08/2008 (update 5/2008)