60A02 Appendices

1. Data Submission Checklist
2. Eligibility Checklist and Registration Form
3. Flow Sheet
4. CES-D
5. Perceived Stress Scale
6. Patient Medication Diary
7. Pill Count
8. Common Toxicity Criteria
9. Performance Status Criteria
10. ADR Contacts
11. Med Watch
12. Baseline Head and Neck Questionnaire
13. Food Questionnaire
14. GI Questionnaire
15. Post Treatment Head and Neck Questionnaire
16. Off Treatment Follow-up Form
17. Blood Sampling for Biomarkers
18. AJCC Staging System
*The contact information for patients seeking the 5 year supply of Juice Plus has changed. Please have patients contact Anita Boddie, RD, PhD by phone at (901) 850-2883 or fax at (901) 850-3055.

*All invoices for biopsies must be submitted to the Research Base PIO attn: Gina Enevold for payment processing. Payments for invoices submitted to other offices will be delayed or may not go through the processing system at all. Please submit all invoices to the following address:

CCCWFU CCOP Research Base
Attn: Gina Enevold
2000 West First Street, Suite 401
Winston-Salem, NC 27104
or fax them in to 336-716-6275.

Quick Reference

Research Base

Fax 336-716-6275
Phone 336-716-0891

2000 West First Street
Protocol Information Office
Suite 101
Winston-Salem, NC 27104
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Last Updated: 09-13-2010
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