98213 Appendices

1. Data Submission Checklist
2. Eligibility Checklist-Registration
3. Performance Status
4. Patient Medication Diary
5. Medwatch
6. Flow-Sheet-TAS Sheet-Addendum
7. Study Parameter Table
8. Statin Medication List
9. Baseline Statin Questionnaire
10.Chemotherapy Treatment Form
11. Radiation Treatment Form
12. MRI Procedure Guidelines
13. Lab Instructions
14. Telephone Contact Form
15. Measuring Waist Circumference 
16. Physician Statin Update Letter
17. Baseline Booklet Instructions and Tests*
18. 6 Month Neurocognitive Booklet*
19. 12 Month Assessment *
20. 18 Month Assessment *
21. 24 Month Assessment *
22. Early Withdrawal Form
23. Baseline Health Questionnaire
24. 6 Month Follow-up Health Questionnaire
25. 24 Month Follow-up Health Questionnaire

98213 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 98213 drop-down box on the right to choose the form.
7. Click on “98213 Forms” at left.
8. Print.
Contact June Fletcher-Steede at jsteede@wfubmc.edu for password information.

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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: 04-23-2014
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