Form 19 CTSU Request for Clinical Brochure

Attachment_1s_clinbroch
Attach_1ee_CTSUIB

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

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 (0925-0624). Do not return the completed form to this address.

Filling out PDF Forms
This PDF form contains “roll-over or double-click ” help functionality.
This form allows you to enter data directly onto the screen. After completing the form,
you are able to print the document so that you can fax/mail the document.

To fill out a form:
1. Select the hand tool.
2. Position the pointer inside a field, and click to type text.
3. After entering text or selecting a check box, do one of the following:
- Press tab to accept the form field change and go to the next form field.
- Press Shift+Tab to accept the form field change and go to the previous form
field.
- Press Enter (Windows) or Return (Mac OS) to accept the form field change and
deselect the current form field.
4. Once completed, print the form.

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

CTSU

Attachment_1s_clinbroch
Attach_1ee_CTSUIB

REQUEST FOR CLINICAL BROCHURE
To request a copy of a Clinical Brochure for an IND, please complete the information below and fax this form the CTSU
Data Center at 1-888-691-8039. 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 #:
______________________________________
Name

___________________
NCI investigator #

Name and phone # of person completing this form:
_______________________________________
Name

(______)________________
phone #

Brochures requested:
PROTOCOL NUMBER

DRUG NAME

NSC NUMBER

l

Name and address (express mail) where document(s) should be sent:
Name: __________________________________________________________________________
Address: ________________________________________________________________________
________________________________________________________________________
City, State, Zip:__________________________/______________________/_________________
Phone: (______)__________________________________________________________________
Email Address: __________________________________________________________________

NCI Investigator number verified?
PMB investigator status is active?
Active on at least one Group Roster?

Yes
Yes
Yes

No
No
No

CTSU use only

Verified by
______________________
Date
_____________________________
Shipment date: _____________________________
Comment:________________________________________________________________________________________
Comment: ________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________

CTSU_IB_v4_July2013
CTSU_IB_v.3_03
authorized by CTSU for local reproduction