www.siopel.com
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 SIOPEL Data Center
     For UK: +44 121 414 9520
     International: +44 207 813 85 88 
*Participating Request for the Study:
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 SIOPEL data center in the UK, if not uploaded in this participating form
Upload scanned signed documents
or fax a copy to SIOPEL 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
Responsible Surgeon
Responsible Pathologist
Responsible Consultant Audiologist or ENT Surgeon (specify which)
Responsible Data Manager
Responsible Pharmacist
 
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:
If yes, please enter your USERID :



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