Appendices

 97509 Appendices

Combined Appendices (Am 2)*

  1. Data Submission Checklist
  2. Eligibility Checklist **    
  3. Performance Status 
  4. Medication Diary    
  5. Med Watch   
  6. Flow Sheet   
  7. Toxicity Assessment Sheet   
  8. Current Medication Form
  9.  Baseline Test Booklet*   
  10.  End RT Test Booklet*  
  11.  4 Week Post RT Test Booklet* 
  12. Monoamine Oxidase Inhibiting Drugs   
  13. Radiation Therapy Summary    
  14.  Brief Fatigue Inventory*   
  15. Telephone Contact Form  

97509 IND Exemption Letter

*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 “Information” on the left side of the green bar at the top of the page.
 6. Use the 97509 drop-down box on the right to choose the form.
 7. Click on “97509 Forms” at left.
 8. Print.
Contact June Fletcher-Steede at jsteede@wfubmc.edu for password information.
   

**Attention Sites Outside of NC:
For sites outside of NC, during registration please fax the following items to Cephalon at (610) 883-5566 in order to receive study drug.

  1. DEA License of Patient's Physician
  2. Pharmacy License (if pharmacy will be receiving Armodafinil)
  3. CCOP Shipping Information (Include: name, address, department, etc) 
  4. Curriculum Vitae or Biosketch of Patient's Physician

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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: 09-26-2011
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Disclaimer: The information on this website is for general informational purposes only and SHOULD NOT be relied upon as a substitute for sound professional medical advice, evaluation or care from your physician or other qualified health care provider.