CCSS | Form - CCSS Application of Intent

Form - CCSS Application of Intent

First Name
Last Name
Institution
Address 1
Address 2
City
State/Province
Country
Zip
Phone
Alternate Phone
Email
A comprehensive review of previously published data has been completed.
The specific aims are clear and focused.
The investigator has appropriate experience and expertise to develop the concept proposal; if not, has identified a mentor or senior co-investigator.
The investigator agrees to develop an initial draft of the concept proposal within 6 weeks of approval of the AOI and to finalize the concept proposal within 6 months.
Project Title
Planned research population (eligibility criteria)
Proposed specific aims
Will the project require non-CCSS funding to complete?: Yes
No
If yes, what would be the anticipated source(s) and timeline(s) for securing funding?
Additional self-reported information: Yes
No
Biological Samples: Yes
No
Medical record data: Yes
No
If yes to any of the above, please briefly describe.
Second Malignancy: Primary
Secondary
Chronic Disease: Primary
Secondary
Reproductive: Primary
Secondary
Neurologic: Primary
Secondary
Psychology / Neuropsychology: Primary
Secondary
Genetics: Primary
Secondary
Cancer Control: Primary
Secondary
Epidemiology / Biostatistics: Primary
Secondary
Late mortality: Primary
Secondary
Correlative Factors
Second Malignancy: Primary
Secondary
Correlative Factors
Tobacco: Primary
Secondary
Correlative Factors
Alcohol: Primary
Secondary
Correlative Factors
Physical activity: Primary
Secondary
Correlative Factors
Medical screening: Primary
Secondary
Correlative Factors
Other: Primary
Secondary
Correlative Factors
If other, please specify
Insurance: Primary
Secondary
Correlative Factors
Marriage: Primary
Secondary
Correlative Factors
Education: Primary
Secondary
Correlative Factors
Employment: Primary
Secondary
Correlative Factors
Other: Primary
Secondary
Correlative Factors
If other, please specify
Hearing/Vision/Speech: Primary
Secondary
Correlative Factors
Hormonal systems: Primary
Secondary
Correlative Factors
Heart and vascular: Primary
Secondary
Correlative Factors
Respiratory: Primary
Secondary
Correlative Factors
Digestive: Primary
Secondary
Correlative Factors
Surgical procedures: Primary
Secondary
Correlative Factors
Brain and nervous system: Primary
Secondary
Correlative Factors
Other: Primary
Secondary
Correlative Factors
If other, please specify
Describe medications
Pregnancy and offspring: Primary
Secondary
Correlative Factors
Family History: Primary
Secondary
Correlative Factors
BSI-18: Primary
Secondary
Correlative Factors
SF-36: Primary
Secondary
Correlative Factors
CCSS-NCQ: Primary
Secondary
Correlative Factors
PTS: Primary
Secondary
Correlative Factors
PTG: Primary
Secondary
Correlative Factors
Other: Primary
Secondary
Correlative Factors
If other, please specify
Chronic conditions (CTCAE v3): Primary
Secondary
Correlative Factors
Health status: Primary
Secondary
Correlative Factors
Age: Primary
Secondary
Correlative Factors
Race: Primary
Secondary
Correlative Factors
Sex: Primary
Secondary
Correlative Factors
Others: Primary
Secondary
Correlative Factors
If others, please specify
Chemotherapy: Correlative Factors
Radiation therapy: Correlative Factors
Surgery: Correlative Factors
CCSS Statistical Center
Local institutional statistician
If local, please provide the name(s) and contact information of the statistician(s) to be involved.
Will this project utilize CCSS biologic samples?: Yes
No
Buccal cell DNA
Peripheral blood
Lymphoblastoid cell lines
Second malignancy pathology samples
Other requiring collection of samples
If other, please explain
Other general comments