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98110 Appendices

  1. Data Submission Checklist
  2. Eligibility Checklist/Registration Form
  3. Performance Status Criteria
  4. Patient Medication Diary
  5. MedWatch
  6. Flow Sheet TAS Addendum
  7. Study Parameters Table
  8.  International Index of Erectile Function*
  9.  Sexual Encounter Profile (SEP)* 
  10.  Expanded Prostate Cancer Index Composite (EPIC-26) Short Form* 
  11.  Global Efficacy Questions* 
  12. Telephone Contact Form
  13. Current Medication Form
  14. Patient Recruitment Letter
  15. Patient Flyer
  16. FACT-P*

*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 98110 drop-down box on the right to choose the form.
 7. Click on “98110 Forms” at left.
 8. Print.
Contact June Fletcher-Steede at for password information.

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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: 12-03-2012
Six Wake Forest Baptist Specialties Earn U.S. News RankingsComprehensive 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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