<p> TACL Therapeutic Advances in Childhood Leukemia & Lymphoma</p><p>TACL Consortium Application for Institutional Membership</p><p>Application Date: Institution Name and Address:</p><p>Proposed Principal Investigator: PI Phone: PI Email: Please attach Biosketch or CV of proposed principal investigator</p><p>Patient Information:</p><p>1. Approximately how many ALL and AML patients does your Institution see per year?</p><p>ALL AML Newly Diagn osed Relapsed</p><p>Scientific Contribution: </p><p>1. How would your Institution contribute to the consortium in proposing and leading Phase I Clinical Trials?</p><p>TACL-Institutional Membership Application Form 1 03/2017 Commitment:</p><p>1. Has your institution ever enrolled patients onto a phase I pediatric oncology clinical trial? Yes No</p><p>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) </p><p>3. Is your institution a member of any other Phase I pediatric oncology consortium? Yes No If yes, please list: </p><p>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.</p><p>Resources:</p><p>1. Do you have an investigational agent pharmacist? Yes No</p><p>2. How many staff of each type do you have and do they have experience working with patients on phase I trials?</p><p># of Staff Experience w/ Phase I</p><p>CRA’s/CRC’s: Yes No</p><p>Research Nurse’s: Yes No</p><p>IRB Support: Yes No</p><p>Non-United States Institutions please answer the following:</p><p>1. What is the process for importing investigational agents into your country?</p><p>2. Please describe your institutions ethics committee or IRB approval process?</p><p>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</p><p>TACL-Institutional Membership Application Form 3 03/2017</p>