Form 3 Withdrawal Form

Attachment_A03_IRB Withdrawal

OMB# 0925-0753
Expiration Date 07/31/2021

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burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974,
ATTN: PRA (0925-0753). Do not return the completed form to this address.

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OMB# 0925-0753
Expiration Date 07/31/2021

Attachment_A03_IRB Withdrawal

Submit to the CTSU Regulatory
Office via the Regulatory
Submission Portal: www.ctsu.org.

Cancer Trials Support Unit
Optional form 1
Withdraw from Protocol
Participation
Institution Name (List all institutions permanently closing this study)

NCI Institution Code : (ALXXX)

Protocol Title: (Shortened version acceptable)

Protocol Number:

Rationale for Study Closure: (Select the answer that best describes the closure)
1) No subjects were accrued at the institution(s) listed above, and
the protocol is now closed to accrual by the sponsoring
organization.
2) No subjects were accrued at the institution(s) listed above, and the
study has been closed with the local IRB with no anticipation of
future accrual (If the protocol is re-opened at a later date the site
must submit an initial approval).
3) All subjects accrued at local institutions have completed treatment
and follow-up and no further accruals are anticipated at the
institution(s) listed above.
4) IRB/Ethics board responsibilities for the protocol listed above
are being transferred to another IRB. Review responsibilities at
IRB #
are being transferred to IRB#
(Please note that initial review of this protocol from the new IRB
must be submitted to the CTSU. Submission of this form only
documents withdraw of the approval from the originating IRB.)
Date of IRB/Ethics Board Action:

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The institutional staff signing below certifies that the information provided above is correct.
Name of Signatory:
Name of approving Organization:
Title of Signatory:

Phone
(

Signature:

Date:

Final_July_2018
Authorized by CTSU for local reproduction

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