<table style="width:100%;">
<colgroup>
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</colgroup>
<tbody>
<tr class="odd">
<td colspan="18">NIH-986 (REV. 02/04)</td>
<td colspan="3">12/00</td>
<td></td>
</tr>
<tr class="even">
<td colspan="9"><p><strong>Return Drug List</strong></p>
<p><strong>DCP Version of NIH Form 986</strong></p>
<h1 id="section"></h1></td>
<td colspan="8" rowspan="8"><p>Address: (Including Institution)</p>
<p>Re:</p></td>
<td colspan="4"><h4 id="for-nci-use-only">FOR NCI USE ONLY</h4></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="9"><p><strong>DIVISION OF CANCER PREVENTION</strong></p>
<h5 id="national-cancer-institute-nih">NATIONAL CANCER INSTITUTE,
NIH</h5></td>
<td colspan="4" rowspan="2"><strong>Return. No.:</strong></td>
<td></td>
</tr>
<tr class="even">
<td colspan="9" rowspan="3"><p><em><strong>Request only agents
<u>supplied</u> by the</strong></em></p>
<h6 id="national-cancer-institute"> National Cancer Institute</h6></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="4"><strong>Signature of Authorizing Official:</strong></td>
<td></td>
</tr>
<tr class="even">
<td colspan="4" rowspan="3"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="9">The agents listed below were ordered by (one
investigator per form only):</td>
<td></td>
</tr>
<tr class="even">
<td colspan="9" rowspan="3"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="4">Date of Authorization:</td>
<td></td>
</tr>
<tr class="even">
<td colspan="8" rowspan="2"><p><strong>□ Check here if returned receipt
should be mailed to the</strong></p>
<p><strong>above address, OR fill in a fax number
below</strong></p></td>
<td colspan="4" rowspan="2"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="9"><strong>NCI Investigator No.:</strong></td>
<td></td>
</tr>
<tr class="even">
<td></td>
<td colspan="2">NSC</td>
<td colspan="2">Agent Name</td>
<td>NCI Protocol</td>
<td colspan="5">Strength, Unit, &amp; Dose Form</td>
<td>Lot Number</td>
<td colspan="4">Manufacturer</td>
<td>Quantity</td>
<td colspan="2" rowspan="2"><strong>Container Number</strong></td>
<td colspan="2" rowspan="2"><strong>Action</strong></td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="2"><p>Number</p>
<p>(if applicable)</p></td>
<td colspan="2"></td>
<td>Number</td>
<td colspan="5">(Specify vials, capsules, or tablets)</td>
<td>(or Patient ID for Blinded Trial)</td>
<td colspan="4"></td>
<td>(Specify whole or partial containers)</td>
<td></td>
</tr>
<tr class="even">
<td>1</td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
<td colspan="5"></td>
<td></td>
<td colspan="4"></td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="4">Reason for return: □ Agent expired</td>
<td colspan="3">□ All patient(s) off treatment.</td>
<td colspan="3">□ Protocol complete</td>
<td>Other:</td>
<td colspan="5"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
</tr>
<tr class="even">
<td>2</td>
<td></td>
<td colspan="3"></td>
<td></td>
<td colspan="5"></td>
<td></td>
<td colspan="4"></td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="4">Reason for return: □ Agent expired</td>
<td colspan="3">□ All patient(s) off treatment.</td>
<td colspan="3">□ Protocol complete</td>
<td>Other:</td>
<td colspan="5"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
</tr>
<tr class="even">
<td>3</td>
<td></td>
<td colspan="3"></td>
<td></td>
<td colspan="5"></td>
<td></td>
<td colspan="4"></td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="4">Reason for return: □ Agent expired</td>
<td colspan="3">□ All patient(s) off treatment.</td>
<td colspan="3">□ Protocol complete</td>
<td>□ Other:</td>
<td colspan="5"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
</tr>
<tr class="even">
<td>4</td>
<td></td>
<td colspan="3"></td>
<td></td>
<td colspan="5"></td>
<td></td>
<td colspan="4"></td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="4">Reason for return: □ Agent expired</td>
<td colspan="3">□ All patient(s) off treatment.</td>
<td colspan="3">□ Protocol complete</td>
<td>□ Other:</td>
<td colspan="5"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
</tr>
<tr class="even">
<td>5</td>
<td></td>
<td colspan="3"></td>
<td></td>
<td colspan="5"></td>
<td></td>
<td colspan="4"></td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="4">Reason for return: □ Agent expired</td>
<td colspan="3">□ All patient(s) off treatment.</td>
<td colspan="3">□ Protocol complete</td>
<td>□ Other:</td>
<td colspan="5"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
</tr>
<tr class="even">
<td>6</td>
<td></td>
<td colspan="3"></td>
<td></td>
<td colspan="5"></td>
<td></td>
<td colspan="4"></td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="4">Reason for return: □ Agent expired</td>
<td colspan="3">□ All patient(s) off treatment.</td>
<td colspan="3">□ Protocol complete</td>
<td colspan="3">□ Other:</td>
<td colspan="3"><strong>Date Received:</strong></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
</tr>
<tr class="even">
<td colspan="14"><strong>INSTRUCTIONS</strong>: (Please refer to
Guidelines for Returning Drugs to DCP Repository for more detailed
instructions)</td>
<td></td>
<td colspan="6" rowspan="4"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="7">1. Properly complete all sections to receive credit for
the return.</td>
<td colspan="7">6. Pack the agent(s) well to minimize breakage and
leakage.</td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td colspan="7"><p>2. Type all information-one item, or lot per line</p>
<p>.</p></td>
<td colspan="7">7. All agents may be returned via room temperature
shipment.</td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="7">3. If returning agents for more than one protocol, each
protocol MUST HAVE its own Return Drug List</td>
<td colspan="7">8. Enclose the completed list with the agent(s) and
return to:</td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td colspan="7">4. DO NOT mark in shaded areas.</td>
<td colspan="3"></td>
<td colspan="3" rowspan="6"><p>DCP Repository</p>
<p>20301 Century Blvd.</p>
<p>Bldg 6 Suite 800</p>
<p>Germantown, MD 20874</p>
<p>Attn: Returns</p></td>
<td></td>
<td rowspan="4"></td>
<td colspan="6" rowspan="4"><strong>RETURN RECEIPT</strong>: To obtain a
return receipt by fax, provide your number in the space below.</td>
<td></td>
</tr>
<tr class="odd">
<td colspan="7">5. Investigator signature or signature of individual
preparing this form:</td>
<td colspan="3"></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td colspan="4"></td>
<td colspan="6"></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="4" rowspan="2"><em>Signature / Printed Name</em></td>
<td colspan="6" rowspan="2"><em>Date</em></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td></td>
<td></td>
<td colspan="5"></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="4"><em>Title</em></td>
<td colspan="3"><em>Phone No.</em></td>
<td colspan="3"></td>
<td></td>
<td></td>
<td colspan="5"></td>
<td></td>
<td></td>
</tr>
</tbody>
</table>