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Required format:

rvCcLUnnnysoCtM8MeNGdLNUBMVPQoH5YhaEjGzuE9rzScrkQezVBtgQfUBXwTMHU

TCI OnCore/Florence Support Ticket

Please complete the Information below. We will respond to your request as soon as possible.

Date

M-D-Y

Request Type

First Name

Last Name

User Role

Disease Team

Please provide your role and functions required in OnCore.

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User/Staff Email

User Network ID (windows username)

Life Number

Clinical Trial Manager Name

PI Name

PI Department (Primary)

PI Department

Is this a NCI National Cooperative Group Protocol?
(Alliance, NRG, SWOG, COG, AMC, BMT-CTN)

Yes No

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Protocol Title

Protocol Type

Treatment or Therapeutic: Protocol designed to evaluate one or more interventions for treating cancer.

Device Feasibility: Protocol designed to evaluate one or more interventions for the feasibility of the product or to test a prototype device and not health outcomes. Such studies are conducted to confirm the design and operating specifications of a device before beginning a full clinical trial

Prevention: Protocol designed to assess one or more interventions aimed at preventing the development of a specific disease or health condition.

Supportive Care: Protocol designed to evaluate one or more interventions where the primary intent is to maximize comfort, minimize side effects, or mitigate against a decline in the participant's health or function. In general, supportive care interventions are not intended to cure a disease.

Diagnostic: Protocol designed to evaluate one of more interventions aimed at identifying a disease or health condition.

Screening: Protocol designed to assess or examine methods of identifying a condition (or risk factor for a condition) in people who are not yet known to have the condition (or risk factor).

Health Services Research: Protocol designed to evaluate the delivery, processes, management, organization, or financing of health care.

Basic Science: Protocol designed to examine the basic mechanisms of action (e.g. physiology, biomechanics) of an intervention.

Other: Not in other categories

Is this a Mount Sinai Investigator Initiated Trial?

Yes

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PI Email Address

PI Network ID

Cactus ID

* must provide value

Please allow up to 5 Business Days to receive the requested information. If needed before then, please note the Due Date in the request and we will do our best to turn it around quickly.

Requestor Name (name of person making the request)

* must provide value

Sponsor Name

Sponsor Protocol Number

Terminated Staff Name

Staff Stop Date/End Date

M-D-Y

Please provide a description of the requested report

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Please select the Trial Types you want included in the report

Treatment Trials Only

All Interventional Trials, including Treatment

Non Interventional Research Only

ALL (Interventional and Non Interventional)

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List the fields required in the report (i.e. Protocol #, PI Name, Dept, Title, Sponsor).

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Enter the Date Range, if applicable. (i.e. open trials 2021, accrual 2018-2021, etc.)

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Request Description

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If issue is with a specific record, please enter the Protocol Number

Requested Completion Date

M-D-Y

Please allow at least 24 hours for this request to be processed.

Requests for External User access to the TCI Florence eBinders should be submitted at least 2 weeks prior to a monitoring visit. If access is required within the next 72 hours, please submit this ticket AND submit an email to TCIFlorence@mssm.edu

External User Name

External User Company Name

External User Email Address

New User Access or Renewal?

Please provide either the DFG, PRMC, or RUTH number:

DFG or PRMC Number

RUTH Number

External User Access Start Date

External User Access End Date

External User Training Certificate

Upload file

Upload any required Documents -1

Upload file

Upload any required documents - 2

Upload file

Upload any required documents - 3

Upload file

Type of Calendar Build Request

* must provide value

Upload Protocol (clean copy)

* must provide value

Upload file

Protocol Version

* must provide value

Protocol Version Date

* must provide value

M-D-Y

NCT Number

Does the protocol require pretreatment before arm designation

Do new arms/cohorts need to be added?

Yes

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Please list the names of how those arms/cohorts should be added

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Any additional comments for the calendar build

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Please note: There is a fee of $208 that will be applied to the initial build and any amendment calendar build request thereafter.

Deviations Training - PEAK Certificate

Upload file

Florence PEAK Training Certificate

Upload file

Study Identifier (DFG, PRMC, or RUTH #) if applicable

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