Please complete the following steps:
1) fill in the form
2) print the completed form and collect signatures
3) fax the form with the signatures to CINECA +39 051 6171 365
We agree to:
* comply with the protocol requirements
* provide the necessary information through the Cineca Remote Data Entry system for central review in a timely manner
* obtain the necessary ethical and regulatory approval required by your country prior to entry the first patient
*
Institutional Review Board (IRB) or Ethics Committee (EC) approval
fax
or Upload
Date of approval:
dd
mm
yyyy
*
Health Authority and/or other applicable approval as required by national regulations
YES
NO
If YES:
fax
or Upload
Date of approval:
dd
mm
yyyy
Group:
* Group:
Group Code:
(filled in by the system)
Group Name:
Search
Explore
(If center do not belong to any group enter other)
If other, specify:
Participating Center:
* Hospital/Institution name:
* Department name:
* Address:
* Zip Code:
* City:
* Country:
Search
Explore
* Telephone:
* FAX:
* Responsible Clinician:
* Surname:
* Forename:
Address (if different from above):
* Telephone:
* E-mail:
Signature:
Signature Date:
dd
mm
yyyy
Please click on the checkbox to fill in data:
Biological Molecular Laboratory
* Surname
* Forename:
* Telephone:
* E-mail:
Signature:
Signature Date:
dd
mm
yyyy
Responsible Cytogenetic Laboratory
* Surname:
* Forename:
* Telephone:
* E-mail:
Signature:
Signature Date:
dd
mm
yyyy
Responsible Morphological Laboratory
* Surname:
* Forename:
* Telephone:
* E-mail:
Signature:
Signature Date:
dd
mm
yyyy
Responsible Flowcytometry Laboratory
* Surname:
* Forename:
* Telephone:
* E-mail:
Signature:
Signature Date:
dd
mm
yyyy
Responsible Data Manager
* Surname:
* Forename:
* Telephone:
* E-mail:
Signature:
Signature Date:
dd
mm
yyyy
* Data input will be done by:
Center
Group Data Center
Back