CCSS Applications of Intent Main Page

CCSS Application of Intent

Asterisk (*) indicates a required field.

Contact Information

First Name*

Last Name*

Institution*

Address 1*

Address 2

City*

State/Province/Region*

Country*

Zip/Postal Code*

Phone Number*

Alternate Phone Number

Email Address*

Project Requirements and Description

Requirements to submit AOI

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?

Does this project require contact of CCSS study subjects for:

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.

What CCSS Working Group(s) would likely be involved? (Check all that apply)

Second Malignancy

Primary Secondary

Chronic Disease

Primary Secondary

Psychology / Neuropsychology

Primary Secondary

Genetics

Primary Secondary

Cancer Control

Primary Secondary

Epidemiology / Biostatistics

Primary Secondary

Outcomes or Correlative Factors

To describe the anticipated scope of the study, please indicate the specific CCSS data to be included as outcome (primary or secondary) or correlative factors. (Check all that apply)

Late mortality

Primary Secondary Correlative Factors

Second Malignancy

Primary Secondary Correlative Factors

Health Behaviors

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

Psychosocial

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

Medical Conditions

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

Medications

Describe medications

Psychologic/Quality of Life

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

Other

Pregnancy and offspring

Primary Secondary Correlative Factors

Family history

Primary Secondary Correlative Factors

Chronic conditions (CTCAE v3)

Primary Secondary Correlative Factors

Health status

Primary Secondary Correlative Factors

Demographic

Age

Primary Secondary Correlative Factors

Race

Primary Secondary Correlative Factors

Sex

Primary Secondary Correlative Factors

Other

Primary Secondary Correlative Factors

If other, please specify

Cancer treatment

Chemotherapy

Correlative Factors

Radiation therapy

Correlative Factors

Surgery

Correlative Factors

Anticipated Sources of Statistical Support

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

If yes, which of the following?

If other, please explain

Other General Comments

Other General Comments

I agree to share this information with St. Jude*
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