SIOPEL Registry
PARTICIPATION FORM
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 CCLG Data Center on + 44 116 254 9504
*Participating Request for the Study:
SIOPEL 4
SIOPEL 5
SIOPEL 6
SIOPEL RCN
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 our country prior to entry the first patient, and supply a copy to the CCLG data center in the UK, if not uploaded in this participating form
Upload scanned signed documents
or fax a copy to CCLG Data Center:
Signed Form of Participation (this form)
fax
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
fax
or Upload
Date of approval:
dd
mm
yyyy
Participating Center:
* Hospital/Institution name:
* Department name:
* Address:
* Zip Code:
* City:
* Country:
Search
Explore
* Telephone:
* FAX:
* Responsible Physician:
* Surname:
* Forename:
Clinician address (if different from above):
* Clinician Telephone:
* Clinician E-mail:
Signature:
Signature Date:
dd
mm
yyyy
Please click on the checkbox to fill in data:
Responsible Radiologist
* Surname
* Forename:
* Telephone:
* E-mail:
Signature:
Signature Date:
dd
mm
yyyy
Responsible Surgeon
* Surname:
* Forename:
* Telephone:
* E-mail:
Signature:
Signature Date:
dd
mm
yyyy
Responsible Pathologist
* Surname:
* Forename:
* Telephone:
* E-mail:
Signature:
Signature Date:
dd
mm
yyyy
Responsible Consultant Audiologist or ENT Surgeon (specify which)
* Surname:
* Forename:
* Telephone:
* E-mail:
Consultant Audiologist
ENT Surgeon
Clear Selection
Signature:
Signature Date:
dd
mm
yyyy
Responsible Data Manager
* Surname:
* Forename:
* Telephone:
* E-mail:
Signature:
Signature Date:
dd
mm
yyyy
Responsible Pharmacist
* Surname
* Forename:
* Telephone:
* E-mail:
Signature:
Signature Date:
dd
mm
yyyy
LABORATORY (complete for SIOPEL 4 and SIOPEL 5 only):
* Laboratory Name
Units and range*:
Range*
Test
Unit*
Min
Max
Haemoglobin
White Blood Cells Count
Neutrophilis
Platelets
AFP
Beta HCG
Previously Registered for RDE system:
Do you already have an USERID for the RDE system:
Yes
No
If yes, please enter your USERID :
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