<table style="width:100%;">
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</colgroup>
<tbody>
<tr class="odd">
<td colspan="17">NIH-986 (REV. 02/04)</td>
<td colspan="2">12/00</td>
<td></td>
</tr>
<tr class="even">
<td colspan="8"><p><strong>Study Site Inventory Balance
Report</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>Email address:</p>
<p>Re: Inventory balance return for Dr. study entitled</p></td>
<td colspan="3"><h4 id="for-nci-use-only">FOR NCI USE ONLY</h4></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="8"><p><strong>DIVISION OF CANCER PREVENTION</strong></p>
<h5 id="national-cancer-institute-nih">NATIONAL CANCER INSTITUTE,
NIH</h5></td>
<td colspan="3" rowspan="2"><strong>Return. No.:</strong></td>
<td></td>
</tr>
<tr class="even">
<td colspan="8" rowspan="3"><p><em><strong>Request only agents
<u>supplied</u> by the</strong></em></p>
<p><em><strong>National Cancer Institute</strong></em></p></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="3"><strong>Signature of Authorizing Official:</strong></td>
<td></td>
</tr>
<tr class="even">
<td colspan="3" rowspan="3"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="8">The agents listed below were ordered by (one
investigator per form only):</td>
<td></td>
</tr>
<tr class="even">
<td colspan="8" rowspan="3"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="3">Date of Authorization:</td>
<td></td>
</tr>
<tr class="even">
<td colspan="8" rowspan="2"><strong>□ Check here if you have returned
all agent(s) supplied to you by the National Cancer Institute back to
DCP Repository</strong></td>
<td colspan="3" rowspan="2"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="8"><strong>NCI Investigator No.:</strong></td>
<td></td>
</tr>
<tr class="even">
<td></td>
<td>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">Barcode label #</td>
<td><p>Quantity</p>
<p>Inventoy</p></td>
<td colspan="2" rowspan="2"></td>
<td rowspan="2"></td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td><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></td>
<td colspan="4">(Barcode label on original bottles from DCP)</td>
<td>(Specify whole or partial containers)</td>
<td></td>
</tr>
<tr class="even">
<td>1</td>
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="5"></td>
<td></td>
<td colspan="4"></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="3"></td>
<td colspan="3"></td>
<td colspan="3"></td>
<td></td>
<td colspan="5"></td>
<td colspan="2"></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>2</td>
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="5"></td>
<td></td>
<td colspan="4"></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="3"></td>
<td colspan="3"></td>
<td colspan="3"></td>
<td></td>
<td colspan="5"></td>
<td colspan="2"></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>3</td>
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="5"></td>
<td></td>
<td colspan="4"></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="3"></td>
<td colspan="3"></td>
<td colspan="3"></td>
<td></td>
<td colspan="5"></td>
<td colspan="2"></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>4</td>
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="5"></td>
<td></td>
<td colspan="4"></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="3"></td>
<td colspan="3"></td>
<td colspan="3"></td>
<td></td>
<td colspan="5"></td>
<td colspan="2"></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>5</td>
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="5"></td>
<td></td>
<td colspan="4"></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="3"></td>
<td colspan="3"></td>
<td colspan="3"></td>
<td></td>
<td colspan="5"></td>
<td colspan="2"></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>6</td>
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="5"></td>
<td></td>
<td colspan="4"></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="3"></td>
<td colspan="3"></td>
<td colspan="3"></td>
<td colspan="3"></td>
<td colspan="3"><strong>Date Received:</strong></td>
<td colspan="2"></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td colspan="13"><strong>INSTRUCTIONS</strong>: (Please refer to
Guidelines for Submitting Study Site Inventory Balance Reports for more
detailed instructions)</td>
<td></td>
<td colspan="5" rowspan="4"><p><strong>Return completed form
to:</strong></p>
<p id="dcp-repository" class="heading">DCP Repository</p>
<p><strong>Fax: 301-515-4297</strong></p>
<p><strong>Email: <a
href="mailto:dcprepository@mckessonbio.com">dcprepository@mckessonbio.com</a></strong></p>
<p><strong>Attn: INVENTORY BALANCE</strong></p></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="6">1. The Inventory Balance Report is to be completed on
the last day of each month</td>
<td colspan="7">6. If submitting reports for more than one protocol,
each protocol MUST have its own Inventory Balance Report</td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td colspan="6"><p>2. Return completed report by the 5<sup>th</sup> of
the following month</p>
<p>.</p></td>
<td colspan="7">7. DO NOT mark in shaded areas</td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="6">3. Properly complete all sections to receive credit for
the return.</td>
<td colspan="7">8. Return the completed form to:</td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td colspan="6">4. Type all information-one item, or lot per line.</td>
<td colspan="6"></td>
<td></td>
<td rowspan="3"></td>
<td colspan="5" rowspan="3"><p><strong>Contact Number</strong>: Provide
your FAX number and telephone number in the space below.</p>
<p><strong>Fax:</strong></p></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="6">5. Investigator signature or signature of individual
preparing this form:</td>
<td colspan="6"></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td colspan="3" rowspan="2"><p id="signature-printed-name"
class="heading">Signature / Printed Name</p></td>
<td colspan="6" rowspan="2"><h6 id="date">Date</h6></td>
<td colspan="3" rowspan="2"><h6 id="title">Title</h6></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td></td>
<td colspan="5"><strong>Phone:</strong></td>
<td></td>
</tr>
</tbody>
</table>