7/26/2017 12:00:00 AM

New Participant Demographics Form

PLEASE SUBMIT THIS QUESTIONNAIRE AS SOON AS POSSIBLE, AS WE ARE UNABLE TO ACTIVATE
YOUR INSTITUTION UNTIL ALL INFORMATION IS RECEIVED. THANK YOU.
TELEPHONE (713) 745-8989 FAX (713) 794-1364 Email IROCHouston@mdanderson.org

THE IROC Houston QA Center ONLY MONITORS INSTITUTIONS THAT PARTICIPATE IN CLINICAL TRIALS
MY INSTITUTION IS A MEMBER OF THE FOLLOWING CLINICAL TRIAL GROUP(S)(i.e RTOG, EORTC, etc.)
   
MY INSTITUTION IS APPLYING FOR MEMBERSHIP IN THE FOLLOWING CLINICAL TRIAL GROUP(S):
   
My institution participates in trials using (click all that apply):  
Institution Name:
Institution Address:
City: State:
Zip: Country:
Name of person to whom OSLD/TLD should be sent:
Does your institution have proton therapy?  
Address where OSLD/TLD is sent:
City: State:
Zip: Country:
Name of Billing person:
Billing Address:
City: State:
Zip: Country:
Physicist of Record:
Physicist's E-mail Address:
Physicist's Phone Number:
Departmental Phone Number:
Departmental Facsimile Number:
Radiation Oncologist of Record name: Email:
Radiologist of Record name: Email:
Physician's Phone Number:
Contact person for data missing from protocol patient's records name: Email:
EORTC Members Only:
  Please specify the beam and machine combinations to be audited. Please remember 6 MeV is the lowest electron energy the IROC Houston is able to monitor.
SENDER INFORMATION: (required)
First Name: Last Name:
E-mail Address: Phone Number: