ToxIC Research Progress Report: Sub Registry

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ToxIC Project Track #*

As indicated on research correspondence including Progress Reporting reminder/notification.

Principal Investigator: Last Name*

Principal Investigator: First Name*

Date Progress Report Submitted*

Mentor (if Applicable) and/or Co-Investigator(s)

ToxIC Sub Registry Name*

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PI's ToxIC Site at Time of Approval*

Current ToxIC Site Status*

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If "New" or "N/A" please enter update of your location:

Time Period of Cases [Example: January 1, 2013 – December 31, 2015]*

Total Number of ToxIC Sites Entering Cases into Sub Registry*

Number of Sites Entering Cases into Sub Registry in the Past Year (January 1 - December 31)?*

Total Number of Cases Entered into the Sub Registry*

Number of Cases Entered into the Sub Registry in the Past Year (January 1 - December 31)*

How often do you export data from the sub registry?*

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Do you QA the sub registry data?*

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If "Yes", how often to you QA the data?

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Do you follow back to ToxIC sites directly?*

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If "Yes", how often to you follow back to the ToxIC sites?

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Have you reported the data QA/improvements back to the ToxIC Program?*

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Deliverables Completed (Abstracts, Presentations, Manuscripts)? Enter "None" if applicable. Please include full citation including meeting name, location and dates for abstract or presentation. Attach a copy of deliverable(s).*

Deliverables in Process with Expected Date of Completion:

Has this research undergone any changes to, or updates of, by the local IRB?*

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Please attach copies of any deliverables and/or IRB updates/notifications:

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Have individuals from other ToxIC sites lead any analysis or reporting efforts?*

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If "Yes" please explain their research involvement beyond case reporting:

Has this project led to other research?*

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If "Yes" please explain other research:

Have you pursued funding to support this sub registry?*

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If "Yes" please describe funding sources approached:

Do you have an expected end date for this sub registry?*

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If "Yes" please enter the potential end date (MM/YYYY)

Current PI Contact: Email*

Current PI Contact: Phone*

Current PI Contact: Address*

Are you a current member of ACMT?*

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