National Cancer Institute - PDQ® - Protocol Submission Form

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PDQ® - Protocol Submission Form


	Online PDQ® Protocol Submission Instructions PDQ® Protocol Submission Checklist

Protocol Information

Title:

Protocol ID's #:

Rationale:

Objectives:

Outline:

Protocol Entry Criteria/Disease Characteristics:

Prior/Concurrent Therapy

Surgery:

Chemotherapy

Biologic Therapy

Radiotherapy

Other

Patient Characteristics

Age Range: Sex: male female male and female

Performance Status:

Hematopoietic:

Hepatic:

Renal:

Cardiovascular:

Pulmonary:

Other:

Projected Accrual:

Supporting Information

Is the study currently accruing patients?     yes no
Study Activation Date
Is this study supported by an NIH grant or contract?    yes no
If so, please provide grant/contract number:
Grant Principal Investigator's Name:
Has the study received either of the following approvals?
  NCI Cancer Therapy Evaluation Program
  NCI Cancer Center Protocol Review and Monitoring System
(Please provide signed confirmation of the approvals from the chairperson of the PRMS committee.)

Address Information

Organization:
Study Chairperson:
Street Address:
City:     State:     Zip Code:
Country:
Phone:     Fax:
* Email:
Update Person:
Street Address:
City:     State:     Zip Code:
Country:
Fax:
Email: