SIOPEL RCN
PARTICIPATION FORM
Please complete the following steps:
1) fill in the form
2) print the completed form and sign by Lead Clinician
3) scan and upload or fax the form with the signature to CCLG Data Center on + 44 116 254 9504
We agree to:
* provide the necessary information through the CINECA remote data entry system for central review in a timely manner
Upload scanned signed document
or fax a copy to CCLG Data Center:
Signed Form of Participation (this form)
fax
or upload
As a Collaborating Centre
* We will collect basic patient data on patients with liver tumours:
Yes
No
* We will treat patients according to SIOPEL RCN guidelines:
Yes
No
* We will request any ethical approval or consent appropriate to our local and national requirements:
Yes
No
Our centre has the facilities to carry out:
US:
Yes
No
CT:
Yes
No
MRI:
Yes
No
Serum AFP measurements:
Yes
No
Serum creatinine:
Yes
No
Pure tone audiometry:
Yes
No
GFR, Cr51EDTA or other clearance method:
Yes
No
Echocardiogram:
Yes
No
We have the following supportive care facilities:
Broad spectrum antibiotics:
Yes
No
Safe blood products:
Yes
No
The centre has access to a surgeon experienced in liver tumour surgery:
Yes
No
Participating Center:
* Hospital/Institution name:
* Department name:
* Address:
* Zip Code:
* City:
* Country:
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Telephone:
FAX:
* Responsible Clinitian:
* Surname:
* Forename:
Clinician title:
Clinician address (if different from above):
* Clinician Telephone:
Clinician Fax:
* Clinician E-mail:
Signature:
Signature Date:
dd
mm
yyyy
Details of Data Manager/person responsible for form return (if different from clinician):
* Surname:
* Forename:
Telephone:
Fax:
* E-mail:
Paediatrician/Oncologist:
Surname:
Forename:
Address:
Telephone:
E-mail:
Surgeon:
Surname:
Forename:
Address:
Telephone:
E-mail:
Radiologist:
Surname:
Forename:
Address:
Telephone:
E-mail:
Pathologist:
Surname:
Forename:
Address:
Telephone:
E-mail:
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