Patient’s Initial Consent given for specimen use for research on the patient's cancer? Yes No Patient’s Initial Consent given for specimen use for research unrelated to the patient's cancer? Yes No Patient’s Initial Consent given for further contact regarding specimen? Yes No Date of Consent for Specimen Use MM DD YYYY APPENDIX F PATIENT DRUG INTERACTIONS HANDOUT AND WALLET CARD Instructions for Patient drug interactions handout and wallet card Template Patient Drug Interactions Handout and Wallet Card is a requirement that must meet CTEP Policies & Procedures for non-marketed investigational agents. The instructions below specify which template to use. Please note the drug interactions handout and wallet card require IRB approval before distribution to patients. Instructions to authors: to the table below to determine which template (Template A or Template B) you should use and fill out the appropriate information as instructed by the Only edit the fillable text fields do not template. Use or delete sections below as appropriate. – alter any text outside of the fillable fields. The bracketed instruction text will disappear once you begin typing. Template A: Patient Drug Interactions Handout and a Patient Drug Interactions Wallet Card To be given at the time of enrollment and when updated. A protocol that has more than one non-marketed investigational agent with PK interactions will have a drug interactions handout and drug interactions wallet card for each agent. Assign a letter or a numeral to the Appendix. A convenient wallet-sized information card for the patient to cut out and retain at all times. Suggested texts to complete the templates are on the next page. Use the fillable template and enter information in the fillable fields. Template B: Patient Clinical Wallet Card only To be given to the patient at the time of enrollment. A convenient wallet-sized information card for the patient to cut out and retain at all times. Assign a letter or a numeral to the Appendix. Suggested to complete the template are on the next page. Use the fillable template and information in the fillable fields. When the Patient Drug Interactions Handout and Wallet Card is required and who is responsible for the authorship is summarized in below:
Patient’s Initial Consent given for specimen use for research on the patient's cancer? Yes No Patient’s Initial Consent given for specimen use for research unrelated to the patient's cancer? Yes No Patient’s Initial Consent given for further contact regarding specimen? Yes No Date of Consent for Specimen Use MM DD YYYY APPENDIX F PATIENT DRUG INTERACTIONS HANDOUT AND WALLET CARD Instructions for Patient drug interactions handout and wallet card Template Patient Drug Interactions Handout and Wallet Card is a requirement that must meet CTEP Policies & Procedures for non-marketed investigational agents. The instructions below specify which template to use. Please note the drug interactions handout and wallet card require IRB approval before distribution to patients. Instructions to authors: to the table below to determine which template (Template A or Template B) you should use and fill out the appropriate information as instructed by the template. Use or delete sections below as appropriate. Only edit the fillable text fields – do not alter any text outside of the fillable fields. The bracketed instruction text will disappear once you begin typing. Template A: Patient Drug Interactions Handout and a Patient Drug Interactions Wallet Card To be given at the time of enrollment and when updated. A protocol that has more than one non-marketed investigational agent with PK interactions will have a drug interactions handout and drug interactions wallet card for each agent. Assign a letter or a numeral to the Appendix. A convenient wallet-sized information card for the patient to cut out and retain at all times. Suggested texts to complete the templates are on the next page. Use the fillable template and enter information in the fillable fields. Template B: Patient Clinical Wallet Card only To be given to the patient at the time of enrollment. A convenient wallet-sized information card for the patient to cut out and retain at all times. Assign a letter or a numeral to the Appendix. Suggested to complete the template are on the next page. Use the fillable template and information in the fillable fields. When the Patient Drug Interactions Handout and Wallet Card is required and who is responsible for the authorship is summarized in below:
CTEP_Organ_Dysfunction_Protocol_Template.docx