Form 1 Attach 1A - CTSU IRB/Regulatory Approval Transmittal For

Attach_1a_CTSUTS

OMB#0925-xxxx
Expiration Date: xx/xx/xxxx

Public reporting burden for this collection of information is estimated to average 2 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-xxxx). 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-xxxx
Expiration Date: xx/xx/xxxx

Attach_1a_CTSUTS

CTSU Transmittal Sheet
Total Pages Sent (______)

Date Sent:

/
mm

/
dd

yyyy

SEND TO: CTSU CENTRAL REGULATORY OFFICE
ATTN: Coalition of Cancer Cooperative Groups (CCCG)
Suite 1100
1818 Market Street
Philadelphia, PA 19103
FAX: 1-215-569-0206

CTSURegulatory@ctsu.coccg.org
Packet Type:

Original/Mandatory Amendment/Renewal
Correction
Description:

Supplemental Submission:
List all applicable NCI Institution Codes materials apply to:

Updated OHRP assurance information: (attach copy of OHRP printout)
List all applicable NCI Institution Codes assurance applies to:
______________________________________________________
Other:
List all applicable NCI Institution Codes materials apply to:

Protocol Contact at Site:
First Name

Last Name

Phone

e-mail

Comments:

Final_June2009
Authorized by CTSU for local reproduction