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  1. Data Submission Requirement Form - TAS - Addenda
  2. Eligibility Checklist
  3. Performance Status Criteria
  4. Medication Diary
  5. Medwatch
  6. Data Submission Schedule
  7. Study Parameter Table
  8. Baseline Booklet*
  9. Week 12 Booklet*
  10. Week 24 Booklet*
  11. Week 36 Booklet*
  12. Perceived Cognitive Impairment Questionnaire and Score Sheet*
  13. Telephone Contact Sheet
  14.  Participant Screening Form
  15. Current Medication Form
  16. Early Withdrawal Form

Combined Appendices*

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 97211 drop-down box on the right to choose the form.
 7. Click on “97211 Forms” at left.
 8. Print.
Contact June Fletcher-Steede at for password information.


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: 09-09-2013
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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.

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