Form 16 CTSU P2C Enrollment Transmittal Form

Attachment_1p_p2c_centf

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

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MSC7974,
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7974, Bethesda,
MD 20892-7974,
PRA (0925-0624).
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Bethesda,
MD 20892-7974,
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this address.

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

Attachment_1p_p2centf

CANCER TRIALS SUPPORT UNIT
P2C PATIENT ENROLLMENT TRANSMITTAL FORM
CTSU patient registrars process enrollments between 9:00 AM and 5:00 PM ET, Mon. - Fri. Enrollments
received after 5pm will be processed the next business day unless the CTSU registrars office is notified via the emergency
number of a time of need enrollment. Prior to enrollment, please refer to the enrollment documents on the CTSU members’
web site as some protocols have limited enrollment hours.
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:

3.

Enrollment Contact Person:________________________________Phone: _______________

Enrollment Cover sheet plus (

___________________________________________________
Lead Consortium and NCI Protocol Number (e.g. Mayo P2C #8233)

First name

Last name

Fax: _____________________________

4.

E-mail: ____________________________________

Treating Institution: __________________________________________________________________
Name

City

5.

Treating Institution’s NCI code (e.g. TX001):

6.

Treating MD: ________________________________________ CTEP ID:
First name

7.

) page(s)

State

Last name

Name of N01 consortium to receive enrollment credit:
Mayo P2C (MPC)

Ohio State University P2C (OSU-CSM)

M.D. Anderson P2C (MDAC)

Princess Margaret Hospital P2C (PMHC)

Memorial Sloan Kettering P2C (MSKC)

U. of California-Davis P2C (UCD-CSM)

H.Lee Moffitt P2C (HLMCC-CSM)

U. of Chicago P2C (UCC)

Montefiore Medical Center P2C (MMC)
8.

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

9.
10.

Date patient informed consent signed:__________________
(MM / DD / YYYY)
Date HIPAA authorization signed (if applicable):______________
(MM / DD / YYYY)

To be completed by the CTSU Registrar:
Accrual/Tracking # ________________________________ Patient ID _____________________________