> **Sample Table 1**

**Accrual to NCI Approved Treatment Trials Conducted by Your Research
Base available for Use by CCOPs^1,\ 2^**

**[Directions]{.underline}: Column (1) Provide the Title of the
Treatment Trial**

**Column (3) Indicate pharmacologic phase as Phase I, II, III or
Adjuvant.**

**Column (6) Indicate projected completion date based on current accrual
rate, if applicable.**

+----------------+-----+--------+-----+----+------+--------+--------+
| **(1)**        | *   | *      | *   | *  | **(  | *      |        |
|                | *(2 | *(3)** | *(4 | *( | 6)** | *(7)** |        |
| **Title**      | )** |        | )** | 5) |      |        |        |
|                |     | **Pha  |     | ** | *    | **     |        |
|                | *   | rmacol | **D |    | *Pro | Number |        |
|                | *NC | ogic** | ise | ** | ject | of     |        |
|                | I** |        | ase | Da | ed** | Pati   |        |
|                |     | **P    | Sit | te |      | ents/C |        |
|                | **P | hase** | e** | ** | **   | redits |        |
|                | rot |        |     |    | Comp | Entere |        |
|                | oco |        |     | ** | leti | d^1,2, |        |
|                | l** |        |     | Op | on** | \ 3^** |        |
|                |     |        |     | en |      |        |        |
|                | *   |        |     | ed | **Da |        |        |
|                | *Nu |        |     | ** | te** |        |        |
|                | mbe |        |     |    |      |        |        |
|                | r** |        |     |    |      |        |        |
+----------------+-----+--------+-----+----+------+--------+--------+
|                |     |        |     |    |      | **     | **T    |
|                |     |        |     |    |      | 7/1/07 | otal** |
|                |     |        |     |    |      | thru   |        |
|                |     |        |     |    |      | 6/3    | *      |
|                |     |        |     |    |      | 0/08** | *Since |
|                |     |        |     |    |      |        | Op     |
|                |     |        |     |    |      | *      | ened** |
|                |     |        |     |    |      | *patie |        |
|                |     |        |     |    |      | nts/cr | **     |
|                |     |        |     |    |      | edit** | patien |
|                |     |        |     |    |      |        | ts/cre |
|                |     |        |     |    |      |        | dits** |
+----------------+-----+--------+-----+----+------+--------+--------+
|                |     |        |     |    |      | **/**  | **/**  |
+----------------+-----+--------+-----+----+------+--------+--------+
|                |     |        |     |    |      | **/**  | **/**  |
+----------------+-----+--------+-----+----+------+--------+--------+
|                |     |        |     |    |      | **/**  | **/**  |
+----------------+-----+--------+-----+----+------+--------+--------+
|                |     |        |     |    |      | **/**  | **/**  |
+----------------+-----+--------+-----+----+------+--------+--------+
|                |     |        |     |    |      | **/**  | **/**  |
+----------------+-----+--------+-----+----+------+--------+--------+
|                |     |        |     |    |      | **/**  | **/**  |
+----------------+-----+--------+-----+----+------+--------+--------+

**Total: \_\_\_\_\_/\_\_\_\_\_ \_\_\_\_\_/\_\_\_\_\_\_**

**^1^[Renewal]{.underline} applicants should only count patients/credits
entered through the CCOPS, not through Members/Affiliates.**

**^2^ [New applicants]{.underline} may report members**= **activity,
since CCOPS were not available.**

^**3**^ **For information on [credits]{.underline} see
<http://prevention.cancer.gov/programs-resources/programs/ccop/credit>**

> **Sample Table 2a**

**Accrual to NCI Approved Cancer Prevention and Control Trials conducted
by your Research Base for Use by CCOPS,**

**Members/Affiliates, and other Research Base Members/Affiliates (if for
Intergroup Studies)^1,2.^**

**(List only trials approved by the DCP Cancer Prevention and Control
Protocol Review Committee^3^. In Column (5) indicate projected
completion date based on current accrual rate, if applicable.**

<table>
<colgroup>
<col style="width: 18%" />
<col style="width: 7%" />
<col style="width: 8%" />
<col style="width: 6%" />
<col style="width: 9%" />
<col style="width: 6%" />
<col style="width: 7%" />
<col style="width: 7%" />
<col style="width: 6%" />
<col style="width: 6%" />
<col style="width: 6%" />
<col style="width: 8%" />
</colgroup>
<tbody>
<tr class="odd">
<td rowspan="4"><p><strong>(1)</strong></p>
<p><strong>Title<sup>5</sup></strong></p>
<p><strong>(Precede with an * if</strong></p>
<p><strong>Inter-group Trial)</strong></p></td>
<td rowspan="4"><p><strong>(2)</strong></p>
<p><strong>NCI</strong></p>
<p><strong>Protocol</strong></p>
<p><strong>Number</strong></p></td>
<td rowspan="4"><p><strong>(3)</strong></p>
<p><strong>Target</strong></p>
<p><strong>Sample Size</strong></p></td>
<td rowspan="4"><p><strong>(4)</strong></p>
<p><strong>Date</strong></p>
<p><strong>Opened</strong></p></td>
<td rowspan="4"><p><strong>(5)</strong></p>
<p><strong>Projected Completion Date</strong></p></td>
<td rowspan="4"><p><strong>(6)</strong></p>
<p><strong>Credit<sup>6</sup></strong></p>
<p><strong>Per Entry</strong></p></td>
<td colspan="6"><p><strong>(7)</strong></p>
<p><strong>Number of Subjects/Credits Entered</strong></p></td>
</tr>
<tr class="even">
<td colspan="2"><strong>CCOP<sup>4</sup></strong></td>
<td colspan="2"><strong>Member/Affiliate</strong></td>
<td colspan="2"><p><strong><u>Intergroup Studies<sup>1,
2</sup></u></strong></p>
<p><strong>Other RB Member/Affil*</strong></p></td>
</tr>
<tr class="odd">
<td><p><strong>7/1/07</strong></p>
<p><strong>thru</strong></p>
<p><strong>6/30/08</strong></p></td>
<td><p><strong>Total*</strong></p>
<p><strong>Since</strong></p>
<p><strong>Opened</strong></p></td>
<td><p><strong>7/1/07</strong></p>
<p><strong>thru</strong></p>
<p><strong>6/30/08</strong></p></td>
<td><p><strong>Total*</strong></p>
<p><strong>Since</strong></p>
<p><strong>Opened</strong></p></td>
<td><p><strong>7/1/07</strong></p>
<p><strong>thru</strong></p>
<p><strong>6/30/08</strong></p></td>
<td><p><strong>Total*</strong></p>
<p><strong>Since</strong></p>
<p><strong>Opened</strong></p></td>
</tr>
<tr class="even">
<td><p><strong>(a)</strong></p>
<p><strong>subjects/</strong></p>
<p><strong>credits<sup>6</sup></strong></p></td>
<td><p><strong>(b)</strong></p>
<p><strong>subjects</strong></p></td>
<td><p><strong>(c)</strong></p>
<p><strong>subjects/credits<sup>6</sup></strong></p></td>
<td><p><strong>(d)</strong></p>
<p><strong>subjects</strong></p></td>
<td><p><strong>(e)</strong></p>
<p><strong>subjects/credits<sup>6</sup></strong></p></td>
<td><p><strong>(f)</strong></p>
<p><strong>subjects</strong></p></td>
</tr>
<tr class="odd">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td><strong>/</strong></td>
<td></td>
<td><strong>/</strong></td>
<td></td>
<td><strong>/</strong></td>
<td></td>
</tr>
<tr class="even">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td><strong>/</strong></td>
<td></td>
<td><strong>/</strong></td>
<td></td>
<td><strong>/</strong></td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td><strong>/</strong></td>
<td></td>
<td><strong>/</strong></td>
<td></td>
<td><strong>/</strong></td>
<td></td>
</tr>
<tr class="even">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td><strong>/</strong></td>
<td></td>
<td><strong>/</strong></td>
<td></td>
<td><strong>/</strong></td>
<td></td>
</tr>
</tbody>
</table>

**Subj/Credits Subjects Subj/Credits Subjects Subj/Credits Subjects**

**Column Total for Table 2a: [/]{.underline} [/]{.underline}
[/]{.underline}**

**Grand Total Credits 7/1/07-6/30/08: \_\_\_\_\_\_\_\_\_\_ \[Add credits
in columns 7(a), 7(c), and 7(e)\].**

**^1^ Only include Inter-group trials where the Research is the Data
Coordinating Center.**

**^2^ Do not include Inter-group trials from other Research Bases.**

**^3^ Other than DCP-approved trials may be listed if new applicant.**

**^4^ For DCP approved trials with credit assigned to CCOP only, enter
the number of participants and zero (0) credits**

**^5^ Provide copies of any abstracts/manuscripts related to the trials
listed above.**

**^6^ For information on [credits]{.underline} see
<http://prevention.cancer.gov/programs-resources/programs/ccop/credit>**

> **Sample Table 2b**

**Accrual to Inter-group NCI Approved Cancer Prevention and Control
Trials sponsored by [other CCOP Research Bases]{.underline} for Use by**

**Your Members/Affiliates.**

**(List only trials approved by the DCP Cancer Prevention and Control
Protocol Review Committee.)**

**In Column (5) indicate projected completion date based on current
accrual rate, if applicable.**

+-------------------+------+------+-----+------+---------+----------+
| **(1)**           | **(  | **(  | *   | **(  | **(6)** |          |
|                   | 2)** | 3)** | *(4 | 5)** |         |          |
| **Title^1^**      |      |      | )** |      | *       |          |
|                   | **N  | **   |     | *    | *Number |          |
|                   | CI** | Targ | **  | *Pro | of      |          |
|                   |      | et** | Dat | ject | S       |          |
|                   | **Pr |      | e** | ed** | ubjects |          |
|                   | otoc | **   |     |      | En      |          |
|                   | ol** | Samp | *   | **   | tered** |          |
|                   |      | le** | *Op | Comp |         |          |
|                   | **   |      | ene | leti | **Memb  |          |
|                   | Numb | **Si | d** | on** | er/Affi |          |
|                   | er** | ze** |     |      | liate** |          |
|                   |      |      |     | **Da |         |          |
|                   |      |      |     | te** |         |          |
+-------------------+------+------+-----+------+---------+----------+
|                   |      |      |     |      | **7     | *        |
|                   |      |      |     |      | /1/07** | *Total** |
|                   |      |      |     |      |         |          |
|                   |      |      |     |      | *       | *        |
|                   |      |      |     |      | *thru** | *Since** |
|                   |      |      |     |      |         |          |
|                   |      |      |     |      | **6/    | **       |
|                   |      |      |     |      | 30/08** | Opened** |
+-------------------+------+------+-----+------+---------+----------+
|                   |      |      |     |      |         |          |
+-------------------+------+------+-----+------+---------+----------+
|                   |      |      |     |      |         |          |
+-------------------+------+------+-----+------+---------+----------+
|                   |      |      |     |      |         |          |
+-------------------+------+------+-----+------+---------+----------+
|                   |      |      |     |      |         |          |
+-------------------+------+------+-----+------+---------+----------+
|                   |      |      |     |      |         |          |
+-------------------+------+------+-----+------+---------+----------+
|                   |      |      |     |      |         |          |
+-------------------+------+------+-----+------+---------+----------+

**^1^ Provide copies of any abstracts/manuscripts related to the trials
listed above.**

**Sample Table 3**

> **Cancer Prevention and Control Concepts Approved by NCI for Protocol
> Development (see
> <http://prevention.cancer.gov/programs-resources/programs/ccop/credit>)**
>
> **(List only concepts approved by the DCP Cancer Prevention and
> Control Concept Review Committee since June 1, 2007.) ^1^**
>
> **[Directions]{.underline}: In Column (5) indicate projected
> completion date based on current accrual rate, if applicable.**

+--------------------+-----+---------+-------+-----+-------+--------+
| **(1)**            | *   | **(3)** | **    | *   | **    |        |
|                    | *(2 |         | (4)** | *(5 | (6)** |        |
| **Concept**        | )** | **T     |       | )** |       |        |
|                    |     | arget** | **P   |     | *     |        |
| **Title**          | *   |         | rojec | *   | *Esti |        |
|                    | *NC | *       | ted** | *Pr | mated |        |
|                    | I** | *Sample |       | oje | A     |        |
|                    |     | Size**  | **    | cte | nnual |        |
|                    | **  |         | Proto | d** | Accr  |        |
|                    | Con |         | col** |     | ual** |        |
|                    | cep |         |       | **D |       |        |
|                    | t** |         | **Su  | ura | **(S  |        |
|                    |     |         | bmiss | tio | ubjec |        |
|                    | *   |         | ion** | n** | ts)** |        |
|                    | *Nu |         |       |     |       |        |
|                    | mbe |         | **D   | **o |       |        |
|                    | r** |         | ate** | f** |       |        |
|                    |     |         |       |     |       |        |
|                    |     |         |       | **S |       |        |
|                    |     |         |       | tud |       |        |
|                    |     |         |       | y** |       |        |
+--------------------+-----+---------+-------+-----+-------+--------+
|                    |     |         |       |     | **C   | **Mem  |
|                    |     |         |       |     | COP** | ber/** |
|                    |     |         |       |     |       |        |
|                    |     |         |       |     |       | *      |
|                    |     |         |       |     |       | *Affil |
|                    |     |         |       |     |       | iate** |
+--------------------+-----+---------+-------+-----+-------+--------+
|                    |     |         |       |     |       |        |
+--------------------+-----+---------+-------+-----+-------+--------+
|                    |     |         |       |     |       |        |
+--------------------+-----+---------+-------+-----+-------+--------+
|                    |     |         |       |     |       |        |
+--------------------+-----+---------+-------+-----+-------+--------+
|                    |     |         |       |     |       |        |
+--------------------+-----+---------+-------+-----+-------+--------+
|                    |     |         |       |     |       |        |
+--------------------+-----+---------+-------+-----+-------+--------+
|                    |     |         |       |     |       |        |
+--------------------+-----+---------+-------+-----+-------+--------+
|                    |     |         |       |     |       |        |
+--------------------+-----+---------+-------+-----+-------+--------+

> **Total:**

**^1^New applicants may list trials other than DCP-approved trials.**

**Cancer Prevention and Control Concepts in Development Sample Table 4**

**([Not yet submitted to NCI]{.underline})**

+-----------------------+----------+-----------+-----------+----------+
| **(1)**               | **(2)**  | **(3)**   | **(4)**   | **(5)**  |
|                       |          |           |           |          |
| **Concept**           | **       | **Pr      | **Pr      | *        |
|                       | Target** | ojected** | ojected** | *Total** |
| **Title**             |          |           |           |          |
|                       | **Popu   | **        | **D       | **       |
|                       | lation** | Concept** | uration** | Sample** |
|                       |          |           |           |          |
|                       |          | **Sub     | **of**    | **Size** |
|                       |          | mission** |           |          |
|                       |          |           | **Study** |          |
|                       |          | **Date**  |           |          |
+-----------------------+----------+-----------+-----------+----------+
|                       |          |           |           |          |
+-----------------------+----------+-----------+-----------+----------+
|                       |          |           |           |          |
+-----------------------+----------+-----------+-----------+----------+
|                       |          |           |           |          |
+-----------------------+----------+-----------+-----------+----------+
|                       |          |           |           |          |
+-----------------------+----------+-----------+-----------+----------+
|                       |          |           |           |          |
+-----------------------+----------+-----------+-----------+----------+
|                       |          |           |           |          |
+-----------------------+----------+-----------+-----------+----------+
|                       |          |           |           |          |
+-----------------------+----------+-----------+-----------+----------+
|                       |          |           |           |          |
+-----------------------+----------+-----------+-----------+----------+

> **Sample Table 5**

**CCOP Affiliations**

**Directions: Please include copies of signed Affiliation Agreements
between the Research Base and each CCOP**

+----------------+-----------------+------+-------+-------+---------+
| **(1)**        | **(2)**         | **(  |       |       |         |
|                |                 | 5)** |       |       |         |
| **CCOP Name**  | **Full Name of  |      |       |       |         |
|                | Principal       | **P  |       |       |         |
|                | Investigator**  | roje |       |       |         |
|                |                 | cted |       |       |         |
|                |                 | An   |       |       |         |
|                |                 | nual |       |       |         |
|                |                 | A    |       |       |         |
|                |                 | ccru |       |       |         |
|                |                 | al** |       |       |         |
+----------------+-----------------+------+-------+-------+---------+
|                |                 | *    |       | **C   |         |
|                |                 | *Tre |       | ancer |         |
|                |                 | atme |       | Preve |         |
|                |                 | nt** |       | ntion |         |
|                |                 |      |       | and   |         |
|                |                 |      |       | Cont  |         |
|                |                 |      |       | rol** |         |
+----------------+-----------------+------+-------+-------+---------+
|                |                 | **Pa | **Cr  | **    | **Credi |
|                |                 | tien | edits | Subje | ts^1^** |
|                |                 | ts** | ^1^** | cts** |         |
+----------------+-----------------+------+-------+-------+---------+
|                |                 |      |       |       |         |
+----------------+-----------------+------+-------+-------+---------+
|                |                 |      |       |       |         |
+----------------+-----------------+------+-------+-------+---------+
|                |                 |      |       |       |         |
+----------------+-----------------+------+-------+-------+---------+
|                |                 |      |       |       |         |
+----------------+-----------------+------+-------+-------+---------+
|                |                 |      |       |       |         |
+----------------+-----------------+------+-------+-------+---------+
|                |                 |      |       |       |         |
+----------------+-----------------+------+-------+-------+---------+
|                |                 |      |       |       |         |
+----------------+-----------------+------+-------+-------+---------+

**Total: \[TX: \_\_\_\_\_\_\_ \_\_\_\_\_\_\] \[CC: \_\_\_\_\_\_\_
\_\_\_\_\_\_\_ \]**

**^1^ For information on [credits]{.underline} see
<http://prevention.cancer.gov/programs-resources/programs/ccop/credit>**

**Sample Table 6**

**Member/Affiliate Participation in NCI Approved Cancer Prevention and
Control Clinical Trials**

+--------------------+-------------+--------------+---------+---------+
| **(1)**            | **(2)**     | **(3)**      | **(4)** |         |
|                    |             |              |         |         |
| **Member/Affiliate | **Full Name | **Location** | **Pr    |         |
| Name**             | of**        |              | ojected |         |
|                    |             | **City,      | Annual  |         |
|                    | **Principal | State, Zip** | Ac      |         |
|                    | Inv         |              | crual** |         |
|                    | estigator** |              |         |         |
+--------------------+-------------+--------------+---------+---------+
|                    |             |              | **Pr    |         |
|                    |             |              | otocols |         |
|                    |             |              | a       |         |
|                    |             |              | pproved |         |
|                    |             |              | at your |         |
|                    |             |              | RB      |         |
|                    |             |              | only**  |         |
+--------------------+-------------+--------------+---------+---------+
|                    |             |              | **Sub   | **Credi |
|                    |             |              | jects** | ts^1^** |
+--------------------+-------------+--------------+---------+---------+
|                    |             |              |         |         |
+--------------------+-------------+--------------+---------+---------+
|                    |             |              |         |         |
+--------------------+-------------+--------------+---------+---------+
|                    |             |              |         |         |
+--------------------+-------------+--------------+---------+---------+
|                    |             |              |         |         |
+--------------------+-------------+--------------+---------+---------+
|                    |             |              |         |         |
+--------------------+-------------+--------------+---------+---------+
|                    |             |              |         |         |
+--------------------+-------------+--------------+---------+---------+
|                    |             | **Total:**   | **[\    | **[\    |
|                    |             |              | _\_\_\_ | _\_\_\_ |
|                    |             |              | \_\_\_\ | \_\_\_\ |
|                    |             |              | _\_\_\_ | _\_\_\_ |
|                    |             |              | \_\_\_] | \_\_\_] |
|                    |             |              | {.under | {.under |
|                    |             |              | line}** | line}** |
+--------------------+-------------+--------------+---------+---------+

**^1^ For information on [credits]{.underline} see
<http://prevention.cancer.gov/programs-resources/programs/ccop/credit>**

**Sample Table 7**

**"Prevention Members"**

**Please list the cooperative group members, affiliate programs and/or
cancer center affiliates other than CCOPs that are included in the
application as Prevention Members.**

**Indicate with a (X) which of the following activities the "Prevention
Member" contributes to in a significant way relative to the goals of the
Research Base.**

\(4\) Substantial accrual to chemoprevention studies

\(5\) Leadership in study implementation and management

\(6\) Scientific leadership in the development of prevention clinical
trials

\(7\) Active membership in research base cancer prevention committees

\(8\) Conduct of preclinical studies and/or Phase I and II clinical
trials necessary for drug development

\(9\) Conduct of correlative research, such as that related to
mechanisms of action, biomarkers, molecular targets, etc.

**Include a proposal for each** "**Prevention Member" that describes how
the member will contribute to the goals of the Research Base related to
cancer prevention (See RFA Section IV. 2. B. Form and Content of
Application for CCOP Research Base Award, Section 5: Membership). A
separate budget must be provided for each** "**Prevention Member.**@

+-----------------+------------+-------------+---+---+---+---+---+---+
| **(1)**         | **(2)**    | **(3)**     | * |   |   |   |   |   |
|                 |            |             | * |   |   |   |   |   |
| **M             | **Full     | *           | A |   |   |   |   |   |
| ember/Affiliate | Name of**  | *Location** | r |   |   |   |   |   |
| Name**          |            |             | e |   |   |   |   |   |
|                 | *          | **City,     | a |   |   |   |   |   |
|                 | *Principal | State,      | s |   |   |   |   |   |
|                 | Inve       | Zip**       | o |   |   |   |   |   |
|                 | stigator** |             | f |   |   |   |   |   |
|                 |            |             | S |   |   |   |   |   |
|                 |            |             | i |   |   |   |   |   |
|                 |            |             | g |   |   |   |   |   |
|                 |            |             | n |   |   |   |   |   |
|                 |            |             | i |   |   |   |   |   |
|                 |            |             | f |   |   |   |   |   |
|                 |            |             | i |   |   |   |   |   |
|                 |            |             | c |   |   |   |   |   |
|                 |            |             | a |   |   |   |   |   |
|                 |            |             | n |   |   |   |   |   |
|                 |            |             | t |   |   |   |   |   |
|                 |            |             | C |   |   |   |   |   |
|                 |            |             | o |   |   |   |   |   |
|                 |            |             | n |   |   |   |   |   |
|                 |            |             | t |   |   |   |   |   |
|                 |            |             | r |   |   |   |   |   |
|                 |            |             | i |   |   |   |   |   |
|                 |            |             | b |   |   |   |   |   |
|                 |            |             | u |   |   |   |   |   |
|                 |            |             | t |   |   |   |   |   |
|                 |            |             | i |   |   |   |   |   |
|                 |            |             | o |   |   |   |   |   |
|                 |            |             | n |   |   |   |   |   |
|                 |            |             | * |   |   |   |   |   |
|                 |            |             | * |   |   |   |   |   |
+-----------------+------------+-------------+---+---+---+---+---+---+
|                 |            |             | * | * | * | * | * | * |
|                 |            |             | * | * | * | * | * | * |
|                 |            |             | ( | ( | ( | ( | ( | ( |
|                 |            |             | 4 | 5 | 6 | 7 | 8 | 9 |
|                 |            |             | ) | ) | ) | ) | ) | ) |
|                 |            |             | * | * | * | * | * | * |
|                 |            |             | * | * | * | * | * | * |
+-----------------+------------+-------------+---+---+---+---+---+---+
|                 |            |             |   |   |   |   |   |   |
+-----------------+------------+-------------+---+---+---+---+---+---+
|                 |            |             |   |   |   |   |   |   |
+-----------------+------------+-------------+---+---+---+---+---+---+
|                 |            |             |   |   |   |   |   |   |
+-----------------+------------+-------------+---+---+---+---+---+---+

> **Sample Table 8**

**Reporting On-Site Auditing Activities for Cancer Prevention Trials,
Large-scale e.g., (STAR), and Other Trials, [if
applicable]{.underline}**

**[For Large-scale Prevention Trials]{.underline}, e.g., the Study of
Tamoxifen and Raloxifene (STAR), provide a list of ALL the participating
institutions along with the audit schedule (MUST be provided) using the
Table Format below.**

**[For Other Prevention Trials]{.underline} that include participating
Institutions other than Cooperative Group Treatment Trial institutions,
provide a list of only these other institutions with their Audit
Schedule using the Table Format below.**

<table>
<colgroup>
<col style="width: 8%" />
<col style="width: 10%" />
<col style="width: 7%" />
<col style="width: 9%" />
<col style="width: 14%" />
<col style="width: 7%" />
<col style="width: 7%" />
<col style="width: 6%" />
<col style="width: 9%" />
<col style="width: 8%" />
<col style="width: 9%" />
</colgroup>
<tbody>
<tr class="odd">
<td><strong>NCI Institution No.</strong></td>
<td><strong>Name</strong></td>
<td><strong>Parent</strong></td>
<td><strong>Membership Date</strong></td>
<td><p><strong>Current Status</strong></p>
<p><strong>(Active/Terminated)</strong></p></td>
<td><p><strong>Accrual</strong></p>
<p><strong>______*</strong></p></td>
<td><p><strong>Accrual</strong></p>
<p><strong>______*</strong></p></td>
<td><p><strong>Accrual</strong></p>
<p><strong>______*</strong></p></td>
<td><strong>Accrual Projected for upcoming year____*</strong></td>
<td><strong>Date of last Audit</strong></td>
<td><strong>Date of Next proposed audit</strong></td>
</tr>
<tr class="even">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
</tbody>
</table>

**\*Fill in accrual blank with year (this should cover the preceding 36
months (e.g., 2005, 2006, 2007), if applicable.**