Download Clinical Trials Request Form

Systemic Treatment Funding Model Clinical Trial Request Form
Please complete this form to request a new clinical trial to be considered for funding through the Systemic
Treatment Funding Model.
Please note, for the purpose of the systemic treatment funding model, a clinical trial is an intervention to
evaluate a systemic anti-cancer drug or biologic which has undergone institutional (peer) review and has
obtained ethics approval at the institutional or provincial level.
Prior to completing and submitting the form, please ensure that the clinical trial is not already listed, by
reviewing the list of clinical trials on the Systemic Treatment Funding Model webpage. Please complete all
sections of this form and submit to: [email protected]
Date: Click here to enter a date.
Requestor Name & Title: Click here to enter text.
E-mail: Click here to enter text.
Phone Number: Click here to enter text.
Name of Cancer Center or Hospital: Click here to enter text.
New Clinical Trial Required Information:
Clinical Trial Name: Click here to enter text.
NCT Number: Click here to enter text.
Note: if there is no NCT number associated with the trial, please indicate another ID (e.g. OCT, EudraCT,
etc.)
Has the trial been approved by a Research Ethics Board at the institutional or provincial level?
☐ Yes
☐ No
Name of Research Ethics Board: Click here to enter text.
For Phase 1 and phase 2 non randomized trials, please identify the standard of care the patient would
receive if not on the clinical trial (options include: supportive care, a specific treatment regimen, etc.):
Click here to enter text.
Link to Trial (if available): Click here to enter text.
For CCO Use Only: Date Received: Click here to enter a date.