+---------------------------------+------------------------------------+
| **Cancer Genetics Network       |                                    |
| (CGN)**                         |                                    |
|                                 |                                    |
| **CONCEPT PROPOSAL**            |                                    |
+---------------------------------+------------------------------------+
| **Title:**                      |                                    |
+---------------------------------+------------------------------------+
| **Type of Study:**              |                                    |
+---------------------------------+------------------------------------+
| **Lead Investigator for         | **Sponsoring CGN Principal         |
| Project**                       | Investigator**                     |
|                                 |                                    |
| Name:                           | Name:                              |
|                                 |                                    |
| Institution:                    | Institution:                       |
|                                 |                                    |
| Address:                        | Address:                           |
|                                 |                                    |
| Phone:                          | Phone:                             |
|                                 |                                    |
| Fax:                            | Fax:                               |
|                                 |                                    |
| E-mail:                         | E-mail:                            |
+---------------------------------+------------------------------------+
| **Participating Sites**         |                                    |
+---------------------------------+------------------------------------+
| **Institution and               | **Co-Investigator**                |
| Affiliation**\*                 |                                    |
|                                 |                                    |
| 1\.                             |                                    |
|                                 |                                    |
| 2\.                             |                                    |
|                                 |                                    |
| 3\.                             |                                    |
|                                 |                                    |
| 4\.                             |                                    |
|                                 |                                    |
| 5\.                             |                                    |
|                                 |                                    |
| 6\.                             |                                    |
|                                 |                                    |
| 7\.                             |                                    |
|                                 |                                    |
| 8\.                             |                                    |
|                                 |                                    |
| (Continue as needed)            |                                    |
+---------------------------------+------------------------------------+
| Please attach a **written       |                                    |
| description** of the proposed   |                                    |
| study, not to exceed 3 pages,   |                                    |
| with the following sections:    |                                    |
+---------------------------------+------------------------------------+
| 1.  Title                       | 6.  Study Design                   |
|                                 |                                    |
| 2.  Objectives or Specific Aims | 7.  Statistical Considerations     |
|                                 |                                    |
| 3.  Background                  | 8.  Significance and Future        |
|                                 |     Directions                     |
| 4.  Study Population            |                                    |
|                                 | 9.  Utilization of CGN Resources   |
| 5.  Human Subjects (list any    |                                    |
|     potential issues)           |                                    |
+---------------------------------+------------------------------------+
| **Submit Concept Proposals to** |                                    |
| Heather L. Symecko, M.P.H.      |                                    |
| **Electronic Submission:**      |                                    |
|                                 |                                    |
| **the CGN Program Manager:**    |                                    |
| Cancer Genetics Network         |                                    |
| hsymecko@partners.org           |                                    |
|                                 |                                    |
| 50 Staniford Street, Suite 560  |                                    |
|                                 |                                    |
| Boston, MA 02114-2517           |                                    |
|                                 |                                    |
| FAX: (617) 724-9878             |                                    |
+---------------------------------+------------------------------------+
| \* CGN-PC, CGN-ITG, CFR, SEER,  |                                    |
| SPORE, EDRN, Consortium         |                                    |
| (Specify), etc.                 |                                    |
+---------------------------------+------------------------------------+