Application for Institutional Membership

TACL Therapeutic Advances in Childhood Leukemia & Lymphoma

TACL Consortium Application for Institutional Membership

Application Date: Institution Name and Address:

Proposed Principal Investigator: PI Phone: PI Email: Please attach Biosketch or CV of proposed principal investigator

Patient Information:

1. Approximately how many ALL and AML patients does your Institution see per year?

ALL AML Newly Diagn osed Relapsed

Scientific Contribution:

1. How would your Institution contribute to the consortium in proposing and leading Phase I Clinical Trials?

TACL-Institutional Membership Application Form 1 03/2017 Commitment:

1. Has your institution ever enrolled patients onto a phase I pediatric oncology clinical trial? Yes No

2. If you answered Yes to question #1, please indicate how many patients your institution has entered onto Phase I pediatric oncology studies in the past 2 years. (Please distinguish between cooperative group, industry sponsored and local studies)

3. Is your institution a member of any other Phase I pediatric oncology consortium? Yes No If yes, please list:

4. Please address whether entry on TACL Consortium studies might conflict with other scientific priorities of the institution and how this could affect accrual to TACL studies from your institution.

Resources:

1. Do you have an investigational agent pharmacist? Yes No

2. How many staff of each type do you have and do they have experience working with patients on phase I trials?

# of Staff Experience w/ Phase I

CRA’s/CRC’s: Yes No

Research Nurse’s: Yes No

IRB Support: Yes No

Non-United States Institutions please answer the following:

1. What is the process for importing investigational agents into your country?

2. Please describe your institutions ethics committee or IRB approval process?

TACL-Institutional Membership Application Form 2 03/2017 Questions: Please call Meline Khanpapyan at (323) 361-8718 or e-mail to [email protected] Institutional applications and biosketchs may be submitted to the TACL Operations Center in any of the following ways: Mail: TACL Operations Center Email: TACL Operations Center Childrens Hospital Los Angeles Central Inbox Attn: Meline Khanpapyan 4650 Sunset Blvd. MS#54 [email protected] Los Angeles, CA 90027-6016

TACL-Institutional Membership Application Form 3 03/2017