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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

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


Medical Center Boulevard, 525@Vine 4th floor
Box 573152
Winston-Salem, NC 27157
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Last Updated: 05-09-2016
Wake Forest Baptist Ranked among Nation’s ‘Best Hospitals’  25 Years in a Row by U.S. News & World ReportComprehensive Cancer Centers National Designation is Renewed2017-2018 Best DoctorsNursing Magnet StatusJoint Commission Report

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.

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