Eligibility/Prestudy Data

Contact Anna Kemper & Michelle Kinney prior to submitting data for an eligibility check.

Patient Name:*

Study:*

Coversheet*

Complete OnlineCoversheet Attached

Site CTEP ID*

Did you offer the patient the DCP 001 Study?

YesN/A

If patient consented: Submit signed consent to DCOP; once approved, then complete theDCOP Online Registration Form (Send consent, worksheets, registration confirmation)
If patient declined: Complete the online DCP-001 Reg-No Consent Form (do not send data to DCOP)

Eligibility Checklist

Most current version is used.Completed with notations to indicate all items addressed.Nurse signature and date on all pages.Physician signed/dated, if required.

Documentation

All Op reports submitted; including procedures referenced in physician notes.All Path reports submitted; including procedures referenced in physician notes.Nurse note: includes initial discussion of study with patientAIl prestudy lab reports submitted. Are the tests within the required timeframe?All scan reports submitted. Are the scans within the required timeframe?AIl H&P's and office notes.Height, weight, PS & baseline # of stools documented in nurse note or other data.Documentation of discussion with research base/study coordinator, if applicable.

Consent

Most current consent signed & dated by patient and witnessSeparate HIPPA consent (if applicable)

Forms

Completed Registration Worksheet (if included in protocol)Race/Ethnicity Form completed, signed, and datedDemographic sheet submitted (includes insurance info, address, date of birth)Baseline Adverse Event sheet completed (all attributions are "1")Baseline Medication sheet.Study specific calendar with required baseline tests dated and initialed.

Comments

Oncology Research Nurse*

Today's Date*

Date

Your Email*

example@example.com

ELIGIBILITY/PRESTUDY