Database Form

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Clinical Information Requisition Form from the
Multidisciplinary CRC Database
Title of Proposal
MDACC Protocol Number:
IRB approval date:
Approved: _________
Pending Approval: __________
*Please note: Data will not be released until IRB approval has been obtained
Primary Objective:
Secondary Objectives
1.
2.
3.
Department:
Primary Investigator:
Co-Investigators:
Statistician:
1
Rationale (<200 words):
Statistical Design (< 100 words):
2
Keywords search words (maximum of 5 words):
1.
2.
3.
4.
5.
Will a request also be made for tissue correlatives?
Yes ________
No ________
Please submit requests via email to: Cathy Eng at [email protected]
Pls allow 7-10 business days for review
**Please note: Release of information from the multidisciplinary colorectal database
requires the submission of an annual progress report to the review committee.
--------------------------------------------------------------------------------------------------------------------Multidisciplinary colorectal database allocation proposal review committee:
Medical Oncology: Cathy Eng, Scott Kopetz
Pathology:
Dipen Maru, Stanley Hamilton, Asif Rashid
Radiation Oncology: Christopher Crane
Surgical Oncology: Lee Ellis, Miguel Rodriguez-Bigas
3
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