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Appendices:
1. Data Submission Checklist
2. Eligibility Checklist/Registration Form
3. Performance Status Criteria
4. Patient Medication Diary
5. MedWatch
6. Flow Sheet
7. TAS (Toxicity Assessment Sheet)
8. Patient Survey Form
9. Telephone Contact Form
10. Current Medication Form
11. Certification Procedures
12. Baseline Booklet* (See instructions below)
13. 12 Week Booklet* (See instructions below)
14. 24 Week Booklet* (See instructions below)
15. MRI CD Submission Form
16. Histology Form
Combined Appendices (Am 7) (Appendices 12-14 can be found on CCRBIS.)
Sample Patient Recruitment Letter for Sites
Help Tool: Medication Lists
*1.To obtain these copyrighted forms, please enter CCRBIS.
2. Click on “login CCRBIS” at the top right of the CCRBIS screen.
3. Type Username and Password.
4. Click on “login.”
5. Click on “Info” in the middle of the green bar at the top of the page.
6. Use the first drop-down box on the right to choose booklet. (Baseline,12 wk, or 24 wk)
7. Click on “Forms” at left.
8. Print.
Contact June Fletcher-Steede at jsteede@wfubmc.edu for password information.
WFU Use Only
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