----------------------------------- -----------------------------------
  **Components**                      **Sample Table 1**

  ----------------------------------- -----------------------------------

  ----------------- ------------------------------- --------- --------------------------------------------------------
  **Definition of   **A component is a full                   
  Component:**      consortium member of a CCOP. A            
                    consortium agreement (letter)             
                    between the CCOP organization             
                    and each component must be                
                    included in the application.              
                    OHRP assurance requirements               
                    must be met (see CCOP RFA,                
                    Section VI. 2. A. Cooperative             
                    Agreement Terms and Conditions            
                    of Award, 2.A.1. CCOP Awardees            
                    Responsibilities [Federally               
                    Mandated                                  
                    Requirements)]{.underline}.**             

                                                              

  **Directions:**   **Column**                      **(2)**   **Indicate if component is a hospital, group/office
                                                              practice, or other organization (indicate type). If
                                                              hospital, indicate all applicable codes: 1=Not for
                                                              Profit; 2=Federal Government (VA or MTF); 3=For Profit;
                                                              4=State/County/City Government; 5=Teaching 6=Medical
                                                              School; 7=Approved Residency; 8=Formal Medical
                                                              Affiliation with Student Rotation.**

                                                    **(3)**   **Indicate if hospital has a current American College of
                                                              Surgeons (ACOS) accredited cancer program.**

                                                    **(5)**   **Use new cases diagnosed or receiving primary treatment
                                                              at that hospital or physicians group, practice except
                                                              for basal cell or squamous cell carcinoma of the skin.**

                                                    **(6)**   **Indicate OHRP FWA number.**
  ----------------- ------------------------------- --------- --------------------------------------------------------

+---------------------+------+--------+-----+-------+---+---+------+
| **(1)**             | **(  |        | *   | **    | * |   | **(  |
|                     | 2)** |        | *(3 | (4)** | * |   | 6)** |
| **Name of           |      |        | )** |       | ( |   |      |
| Component**         | **D  |        |     | **    | 5 |   | **OH |
|                     | escr |        | **  | Total | ) |   | RP** |
| **Address**         | ipti |        | ACO | Num   | * |   |      |
|                     | on** |        | S** | ber** | * |   | *    |
| **Telephone         |      |        |     |       |   |   | *Ass |
| Number**            |      |        | **  | **of  | * |   | uran |
|                     |      |        | Acc | Hospi | * |   | ce** |
|                     |      |        | red | tal** | N |   |      |
|                     |      |        | ite |       | u |   | **   |
|                     |      |        | d** | **B   | m |   | Numb |
|                     |      |        |     | eds** | b |   | er** |
|                     |      |        | **  |       | e |   |      |
|                     |      |        | Pro | *     | r |   |      |
|                     |      |        | gra | *(Hos | o |   |      |
|                     |      |        | m** | pital | f |   |      |
|                     |      |        |     | On    | N |   |      |
|                     |      |        | *   | ly)** | e |   |      |
|                     |      |        | *Ye |       | w |   |      |
|                     |      |        | s/N | **2   | C |   |      |
|                     |      |        | o** | 008** | a |   |      |
|                     |      |        |     |       | n |   |      |
|                     |      |        |     |       | c |   |      |
|                     |      |        |     |       | e |   |      |
|                     |      |        |     |       | r |   |      |
|                     |      |        |     |       | P |   |      |
|                     |      |        |     |       | a |   |      |
|                     |      |        |     |       | t |   |      |
|                     |      |        |     |       | i |   |      |
|                     |      |        |     |       | e |   |      |
|                     |      |        |     |       | n |   |      |
|                     |      |        |     |       | t |   |      |
|                     |      |        |     |       | s |   |      |
|                     |      |        |     |       | * |   |      |
|                     |      |        |     |       | * |   |      |
|                     |      |        |     |       |   |   |      |
|                     |      |        |     |       | * |   |      |
|                     |      |        |     |       | * |   |      |
|                     |      |        |     |       | ( |   |      |
|                     |      |        |     |       | I |   |      |
|                     |      |        |     |       | n |   |      |
|                     |      |        |     |       | / |   |      |
|                     |      |        |     |       | O |   |      |
|                     |      |        |     |       | u |   |      |
|                     |      |        |     |       | t |   |      |
|                     |      |        |     |       | p |   |      |
|                     |      |        |     |       | a |   |      |
|                     |      |        |     |       | t |   |      |
|                     |      |        |     |       | i |   |      |
|                     |      |        |     |       | e |   |      |
|                     |      |        |     |       | n |   |      |
|                     |      |        |     |       | t |   |      |
|                     |      |        |     |       | ) |   |      |
|                     |      |        |     |       | * |   |      |
|                     |      |        |     |       | * |   |      |
|                     |      |        |     |       |   |   |      |
|                     |      |        |     |       | * |   |      |
|                     |      |        |     |       | * |   |      |
|                     |      |        |     |       | 2 |   |      |
|                     |      |        |     |       | 0 |   |      |
|                     |      |        |     |       | 0 |   |      |
|                     |      |        |     |       | 6 |   |      |
|                     |      |        |     |       | 2 |   |      |
|                     |      |        |     |       | 0 |   |      |
|                     |      |        |     |       | 0 |   |      |
|                     |      |        |     |       | 7 |   |      |
|                     |      |        |     |       | * |   |      |
|                     |      |        |     |       | * |   |      |
+---------------------+------+--------+-----+-------+---+---+------+
|                     | **   | **If   |     |       |   |   |      |
|                     | H=Ho | Ho     |     |       |   |   |      |
|                     | spit | spital |     |       |   |   |      |
|                     | al** | enter  |     |       |   |   |      |
|                     |      | appl   |     |       |   |   |      |
|                     | **G  | icable |     |       |   |   |      |
|                     | =Gro | c      |     |       |   |   |      |
|                     | up** | odes** |     |       |   |   |      |
|                     |      |        |     |       |   |   |      |
|                     | **O  | **(see |     |       |   |   |      |
|                     | =Oth | ab     |     |       |   |   |      |
|                     | er** | ove)** |     |       |   |   |      |
+---------------------+------+--------+-----+-------+---+---+------+
|                     |      |        |     |       |   |   |      |
+---------------------+------+--------+-----+-------+---+---+------+
|                     |      |        |     |       |   |   |      |
+---------------------+------+--------+-----+-------+---+---+------+
|                     |      |        |     |       |   |   |      |
+---------------------+------+--------+-----+-------+---+---+------+
|                     |      |        |     |       |   |   |      |
+---------------------+------+--------+-----+-------+---+---+------+
|                     |      |        |     |       |   |   |      |
+---------------------+------+--------+-----+-------+---+---+------+

  ----------------------------------- -----------------------------------
  **Affiliates**                      **Sample Table 2**

  ----------------------------------- -----------------------------------

+------+---+---+-------------------------------------------------------+
| **De | > |   |                                                       |
| fini |   |   |                                                       |
| tion | * |   |                                                       |
| of   | * |   |                                                       |
| Affi | O |   |                                                       |
| liat | c |   |                                                       |
| e:** | c |   |                                                       |
|      | a |   |                                                       |
|      | s |   |                                                       |
|      | i |   |                                                       |
|      | o |   |                                                       |
|      | n |   |                                                       |
|      | a |   |                                                       |
|      | l |   |                                                       |
|      | l |   |                                                       |
|      | y |   |                                                       |
|      | , |   |                                                       |
|      | > |   |                                                       |
|      |   |   |                                                       |
|      | a |   |                                                       |
|      | > |   |                                                       |
|      |   |   |                                                       |
|      | C |   |                                                       |
|      | C |   |                                                       |
|      | O |   |                                                       |
|      | P |   |                                                       |
|      | > |   |                                                       |
|      |   |   |                                                       |
|      | m |   |                                                       |
|      | a |   |                                                       |
|      | y |   |                                                       |
|      | > |   |                                                       |
|      |   |   |                                                       |
|      | w |   |                                                       |
|      | a |   |                                                       |
|      | n |   |                                                       |
|      | t |   |                                                       |
|      | > |   |                                                       |
|      |   |   |                                                       |
|      | t |   |                                                       |
|      | o |   |                                                       |
|      | > |   |                                                       |
|      |   |   |                                                       |
|      | e |   |                                                       |
|      | s |   |                                                       |
|      | t |   |                                                       |
|      | a |   |                                                       |
|      | b |   |                                                       |
|      | l |   |                                                       |
|      | i |   |                                                       |
|      | s |   |                                                       |
|      | h |   |                                                       |
|      | > |   |                                                       |
|      |   |   |                                                       |
|      | a |   |                                                       |
|      | > |   |                                                       |
|      |   |   |                                                       |
|      | r |   |                                                       |
|      | e |   |                                                       |
|      | l |   |                                                       |
|      | a |   |                                                       |
|      | t |   |                                                       |
|      | i |   |                                                       |
|      | o |   |                                                       |
|      | n |   |                                                       |
|      | s |   |                                                       |
|      | h |   |                                                       |
|      | i |   |                                                       |
|      | p |   |                                                       |
|      | > |   |                                                       |
|      |   |   |                                                       |
|      | w |   |                                                       |
|      | i |   |                                                       |
|      | t |   |                                                       |
|      | h |   |                                                       |
|      | > |   |                                                       |
|      |   |   |                                                       |
|      | a |   |                                                       |
|      | n |   |                                                       |
|      | > |   |                                                       |
|      |   |   |                                                       |
|      | o |   |                                                       |
|      | r |   |                                                       |
|      | g |   |                                                       |
|      | a |   |                                                       |
|      | n |   |                                                       |
|      | i |   |                                                       |
|      | z |   |                                                       |
|      | a |   |                                                       |
|      | t |   |                                                       |
|      | i |   |                                                       |
|      | o |   |                                                       |
|      | n |   |                                                       |
|      | > |   |                                                       |
|      |   |   |                                                       |
|      | t |   |                                                       |
|      | h |   |                                                       |
|      | a |   |                                                       |
|      | t |   |                                                       |
|      | > |   |                                                       |
|      |   |   |                                                       |
|      | m |   |                                                       |
|      | a |   |                                                       |
|      | y |   |                                                       |
|      | > |   |                                                       |
|      |   |   |                                                       |
|      | b |   |                                                       |
|      | e |   |                                                       |
|      | > |   |                                                       |
|      |   |   |                                                       |
|      | a |   |                                                       |
|      | b |   |                                                       |
|      | l |   |                                                       |
|      | e |   |                                                       |
|      | > |   |                                                       |
|      |   |   |                                                       |
|      | t |   |                                                       |
|      | o |   |                                                       |
|      | > |   |                                                       |
|      |   |   |                                                       |
|      | p |   |                                                       |
|      | u |   |                                                       |
|      | t |   |                                                       |
|      | > |   |                                                       |
|      |   |   |                                                       |
|      | a |   |                                                       |
|      | > |   |                                                       |
|      |   |   |                                                       |
|      | m |   |                                                       |
|      | i |   |                                                       |
|      | n |   |                                                       |
|      | i |   |                                                       |
|      | m |   |                                                       |
|      | u |   |                                                       |
|      | m |   |                                                       |
|      | > |   |                                                       |
|      |   |   |                                                       |
|      | n |   |                                                       |
|      | u |   |                                                       |
|      | m |   |                                                       |
|      | b |   |                                                       |
|      | e |   |                                                       |
|      | r |   |                                                       |
|      | > |   |                                                       |
|      |   |   |                                                       |
|      | o |   |                                                       |
|      | f |   |                                                       |
|      | > |   |                                                       |
|      |   |   |                                                       |
|      | p |   |                                                       |
|      | a |   |                                                       |
|      | t |   |                                                       |
|      | i |   |                                                       |
|      | e |   |                                                       |
|      | n |   |                                                       |
|      | t |   |                                                       |
|      | s |   |                                                       |
|      | > |   |                                                       |
|      |   |   |                                                       |
|      | o |   |                                                       |
|      | n |   |                                                       |
|      | > |   |                                                       |
|      |   |   |                                                       |
|      | p |   |                                                       |
|      | r |   |                                                       |
|      | o |   |                                                       |
|      | t |   |                                                       |
|      | o |   |                                                       |
|      | c |   |                                                       |
|      | o |   |                                                       |
|      | l |   |                                                       |
|      | s |   |                                                       |
|      | > |   |                                                       |
|      |   |   |                                                       |
|      | b |   |                                                       |
|      | u |   |                                                       |
|      | t |   |                                                       |
|      | > |   |                                                       |
|      |   |   |                                                       |
|      | f |   |                                                       |
|      | o |   |                                                       |
|      | r |   |                                                       |
|      | > |   |                                                       |
|      |   |   |                                                       |
|      | w |   |                                                       |
|      | h |   |                                                       |
|      | i |   |                                                       |
|      | c |   |                                                       |
|      | h |   |                                                       |
|      | > |   |                                                       |
|      |   |   |                                                       |
|      | f |   |                                                       |
|      | u |   |                                                       |
|      | l |   |                                                       |
|      | l |   |                                                       |
|      | > |   |                                                       |
|      |   |   |                                                       |
|      | c |   |                                                       |
|      | o |   |                                                       |
|      | n |   |                                                       |
|      | s |   |                                                       |
|      | o |   |                                                       |
|      | r |   |                                                       |
|      | t |   |                                                       |
|      | i |   |                                                       |
|      | u |   |                                                       |
|      | m |   |                                                       |
|      | > |   |                                                       |
|      |   |   |                                                       |
|      | m |   |                                                       |
|      | e |   |                                                       |
|      | m |   |                                                       |
|      | b |   |                                                       |
|      | e |   |                                                       |
|      | r |   |                                                       |
|      | s |   |                                                       |
|      | h |   |                                                       |
|      | i |   |                                                       |
|      | p |   |                                                       |
|      | > |   |                                                       |
|      |   |   |                                                       |
|      | i |   |                                                       |
|      | s |   |                                                       |
|      | > |   |                                                       |
|      |   |   |                                                       |
|      | n |   |                                                       |
|      | o |   |                                                       |
|      | t |   |                                                       |
|      | > |   |                                                       |
|      |   |   |                                                       |
|      | a |   |                                                       |
|      | p |   |                                                       |
|      | p |   |                                                       |
|      | r |   |                                                       |
|      | o |   |                                                       |
|      | p |   |                                                       |
|      | r |   |                                                       |
|      | i |   |                                                       |
|      | a |   |                                                       |
|      | t |   |                                                       |
|      | e |   |                                                       |
|      | . |   |                                                       |
|      | > |   |                                                       |
|      |   |   |                                                       |
|      | O |   |                                                       |
|      | H |   |                                                       |
|      | R |   |                                                       |
|      | P |   |                                                       |
|      | > |   |                                                       |
|      |   |   |                                                       |
|      | a |   |                                                       |
|      | s |   |                                                       |
|      | s |   |                                                       |
|      | u |   |                                                       |
|      | r |   |                                                       |
|      | a |   |                                                       |
|      | n |   |                                                       |
|      | c |   |                                                       |
|      | e |   |                                                       |
|      | > |   |                                                       |
|      |   |   |                                                       |
|      | r |   |                                                       |
|      | e |   |                                                       |
|      | q |   |                                                       |
|      | u |   |                                                       |
|      | i |   |                                                       |
|      | r |   |                                                       |
|      | e |   |                                                       |
|      | m |   |                                                       |
|      | e |   |                                                       |
|      | n |   |                                                       |
|      | t |   |                                                       |
|      | s |   |                                                       |
|      | > |   |                                                       |
|      |   |   |                                                       |
|      | m |   |                                                       |
|      | u |   |                                                       |
|      | s |   |                                                       |
|      | t |   |                                                       |
|      | > |   |                                                       |
|      |   |   |                                                       |
|      | b |   |                                                       |
|      | e |   |                                                       |
|      | > |   |                                                       |
|      |   |   |                                                       |
|      | m |   |                                                       |
|      | e |   |                                                       |
|      | t |   |                                                       |
|      | > |   |                                                       |
|      |   |   |                                                       |
|      | ( |   |                                                       |
|      | s |   |                                                       |
|      | e |   |                                                       |
|      | e |   |                                                       |
|      | > |   |                                                       |
|      |   |   |                                                       |
|      | C |   |                                                       |
|      | C |   |                                                       |
|      | O |   |                                                       |
|      | P |   |                                                       |
|      | > |   |                                                       |
|      |   |   |                                                       |
|      | R |   |                                                       |
|      | F |   |                                                       |
|      | A |   |                                                       |
|      | > |   |                                                       |
|      |   |   |                                                       |
|      | S |   |                                                       |
|      | e |   |                                                       |
|      | c |   |                                                       |
|      | t |   |                                                       |
|      | i |   |                                                       |
|      | o |   |                                                       |
|      | n |   |                                                       |
|      | > |   |                                                       |
|      |   |   |                                                       |
|      | V |   |                                                       |
|      | I |   |                                                       |
|      | . |   |                                                       |
|      | > |   |                                                       |
|      |   |   |                                                       |
|      | 2 |   |                                                       |
|      | . |   |                                                       |
|      | > |   |                                                       |
|      |   |   |                                                       |
|      | A |   |                                                       |
|      | . |   |                                                       |
|      | > |   |                                                       |
|      |   |   |                                                       |
|      | C |   |                                                       |
|      | o |   |                                                       |
|      | o |   |                                                       |
|      | p |   |                                                       |
|      | e |   |                                                       |
|      | r |   |                                                       |
|      | a |   |                                                       |
|      | t |   |                                                       |
|      | i |   |                                                       |
|      | v |   |                                                       |
|      | e |   |                                                       |
|      | > |   |                                                       |
|      |   |   |                                                       |
|      | A |   |                                                       |
|      | g |   |                                                       |
|      | r |   |                                                       |
|      | e |   |                                                       |
|      | e |   |                                                       |
|      | m |   |                                                       |
|      | e |   |                                                       |
|      | n |   |                                                       |
|      | t |   |                                                       |
|      | > |   |                                                       |
|      |   |   |                                                       |
|      | T |   |                                                       |
|      | e |   |                                                       |
|      | r |   |                                                       |
|      | m |   |                                                       |
|      | s |   |                                                       |
|      | > |   |                                                       |
|      |   |   |                                                       |
|      | a |   |                                                       |
|      | n |   |                                                       |
|      | d |   |                                                       |
|      | > |   |                                                       |
|      |   |   |                                                       |
|      | C |   |                                                       |
|      | o |   |                                                       |
|      | n |   |                                                       |
|      | d |   |                                                       |
|      | i |   |                                                       |
|      | t |   |                                                       |
|      | i |   |                                                       |
|      | o |   |                                                       |
|      | n |   |                                                       |
|      | s |   |                                                       |
|      | > |   |                                                       |
|      |   |   |                                                       |
|      | o |   |                                                       |
|      | f |   |                                                       |
|      | > |   |                                                       |
|      |   |   |                                                       |
|      | A |   |                                                       |
|      | w |   |                                                       |
|      | a |   |                                                       |
|      | r |   |                                                       |
|      | d |   |                                                       |
|      | , |   |                                                       |
|      | > |   |                                                       |
|      |   |   |                                                       |
|      | 2 |   |                                                       |
|      | . |   |                                                       |
|      | A |   |                                                       |
|      | . |   |                                                       |
|      | 1 |   |                                                       |
|      | . |   |                                                       |
|      | > |   |                                                       |
|      |   |   |                                                       |
|      | C |   |                                                       |
|      | C |   |                                                       |
|      | O |   |                                                       |
|      | P |   |                                                       |
|      | > |   |                                                       |
|      |   |   |                                                       |
|      | A |   |                                                       |
|      | w |   |                                                       |
|      | a |   |                                                       |
|      | r |   |                                                       |
|      | d |   |                                                       |
|      | e |   |                                                       |
|      | e |   |                                                       |
|      | s |   |                                                       |
|      | > |   |                                                       |
|      |   |   |                                                       |
|      | R |   |                                                       |
|      | e |   |                                                       |
|      | s |   |                                                       |
|      | p |   |                                                       |
|      | o |   |                                                       |
|      | n |   |                                                       |
|      | s |   |                                                       |
|      | i |   |                                                       |
|      | b |   |                                                       |
|      | i |   |                                                       |
|      | l |   |                                                       |
|      | i |   |                                                       |
|      | t |   |                                                       |
|      | i |   |                                                       |
|      | e |   |                                                       |
|      | s |   |                                                       |
|      | > |   |                                                       |
|      |   |   |                                                       |
|      | [ |   |                                                       |
|      | F |   |                                                       |
|      | e |   |                                                       |
|      | d |   |                                                       |
|      | e |   |                                                       |
|      | r |   |                                                       |
|      | a |   |                                                       |
|      | l |   |                                                       |
|      | l |   |                                                       |
|      | y |   |                                                       |
|      | > |   |                                                       |
|      |   |   |                                                       |
|      | M |   |                                                       |
|      | a |   |                                                       |
|      | n |   |                                                       |
|      | d |   |                                                       |
|      | a |   |                                                       |
|      | t |   |                                                       |
|      | e |   |                                                       |
|      | d |   |                                                       |
|      | > |   |                                                       |
|      |   |   |                                                       |
|      | R |   |                                                       |
|      | e |   |                                                       |
|      | q |   |                                                       |
|      | u |   |                                                       |
|      | i |   |                                                       |
|      | r |   |                                                       |
|      | e |   |                                                       |
|      | m |   |                                                       |
|      | e |   |                                                       |
|      | n |   |                                                       |
|      | t |   |                                                       |
|      | s |   |                                                       |
|      | ) |   |                                                       |
|      | ] |   |                                                       |
|      | { |   |                                                       |
|      | . |   |                                                       |
|      | u |   |                                                       |
|      | n |   |                                                       |
|      | d |   |                                                       |
|      | e |   |                                                       |
|      | r |   |                                                       |
|      | l |   |                                                       |
|      | i |   |                                                       |
|      | n |   |                                                       |
|      | e |   |                                                       |
|      | } |   |                                                       |
|      | . |   |                                                       |
|      | * |   |                                                       |
|      | * |   |                                                       |
+------+---+---+-------------------------------------------------------+
|      |   |   |                                                       |
+------+---+---+-------------------------------------------------------+
| **D  | * | * | **Indicate if affiliate is a hospital, group/office   |
| irec | * | * | practice, or other organization (indicate type). If   |
| tion | C | ( | hospital, indicate all applicable codes: 1=Not for    |
| s:** | o | 2 | Profit; 2=Federal Government (VA or MTF); 3=For       |
|      | l | ) | Profit; 4=State/County/City Government; 5=Teaching    |
|      | u | * | 6=Medical School; 7=Approved Residency; 8=Formal      |
|      | m | * | Medical Affiliation with Student Rotation.**          |
|      | n |   |                                                       |
|      | * |   |                                                       |
|      | * |   |                                                       |
+------+---+---+-------------------------------------------------------+
|      |   | * | **Indicate if hospital has a current American College |
|      |   | * | of Surgeons (ACOS) accredited cancer program.**       |
|      |   | ( |                                                       |
|      |   | 3 |                                                       |
|      |   | ) |                                                       |
|      |   | * |                                                       |
|      |   | * |                                                       |
+------+---+---+-------------------------------------------------------+
|      |   | * | **Use new cases diagnosed or receiving primary        |
|      |   | * | treatment at that hospital or physicians group,       |
|      |   | ( | practice except for basal cell or squamous cell       |
|      |   | 5 | carcinoma of the skin.**                              |
|      |   | ) |                                                       |
|      |   | * |                                                       |
|      |   | * |                                                       |
+------+---+---+-------------------------------------------------------+
|      |   | * | **Indicate OHRP FWA number.**                         |
|      |   | * |                                                       |
|      |   | ( |                                                       |
|      |   | 6 |                                                       |
|      |   | ) |                                                       |
|      |   | * |                                                       |
|      |   | * |                                                       |
+------+---+---+-------------------------------------------------------+

+---------------------+------+--------+-----+-------+---+---+------+
| **(1)**             | **(  |        | *   | **    | * |   | **(  |
|                     | 2)** |        | *(3 | (4)** | * |   | 6)** |
| **Name of           |      |        | )** |       | ( |   |      |
| Affiliate**         | **D  |        |     | **    | 5 |   | **OH |
|                     | escr |        | **  | Total | ) |   | RP** |
| **Address**         | ipti |        | ACO | Num   | * |   |      |
|                     | on** |        | S** | ber** | * |   | *    |
| **Telephone         |      |        |     |       |   |   | *Ass |
| Number**            |      |        | **  | **of  | * |   | uran |
|                     |      |        | Acc | Hospi | * |   | ce** |
|                     |      |        | red | tal** | N |   |      |
|                     |      |        | ite |       | u |   | **   |
|                     |      |        | d** | **B   | m |   | Numb |
|                     |      |        |     | eds** | b |   | er** |
|                     |      |        | **  |       | e |   |      |
|                     |      |        | Pro | *     | r |   |      |
|                     |      |        | gra | *(Hos | o |   |      |
|                     |      |        | m** | pital | f |   |      |
|                     |      |        |     | On    | N |   |      |
|                     |      |        | *   | ly)** | e |   |      |
|                     |      |        | *Ye |       | w |   |      |
|                     |      |        | s/N | **2   | C |   |      |
|                     |      |        | o** | 008** | a |   |      |
|                     |      |        |     |       | n |   |      |
|                     |      |        |     |       | c |   |      |
|                     |      |        |     |       | e |   |      |
|                     |      |        |     |       | r |   |      |
|                     |      |        |     |       | P |   |      |
|                     |      |        |     |       | a |   |      |
|                     |      |        |     |       | t |   |      |
|                     |      |        |     |       | i |   |      |
|                     |      |        |     |       | e |   |      |
|                     |      |        |     |       | n |   |      |
|                     |      |        |     |       | t |   |      |
|                     |      |        |     |       | s |   |      |
|                     |      |        |     |       | * |   |      |
|                     |      |        |     |       | * |   |      |
|                     |      |        |     |       |   |   |      |
|                     |      |        |     |       | * |   |      |
|                     |      |        |     |       | * |   |      |
|                     |      |        |     |       | ( |   |      |
|                     |      |        |     |       | I |   |      |
|                     |      |        |     |       | n |   |      |
|                     |      |        |     |       | / |   |      |
|                     |      |        |     |       | O |   |      |
|                     |      |        |     |       | u |   |      |
|                     |      |        |     |       | t |   |      |
|                     |      |        |     |       | p |   |      |
|                     |      |        |     |       | a |   |      |
|                     |      |        |     |       | t |   |      |
|                     |      |        |     |       | i |   |      |
|                     |      |        |     |       | e |   |      |
|                     |      |        |     |       | n |   |      |
|                     |      |        |     |       | t |   |      |
|                     |      |        |     |       | ) |   |      |
|                     |      |        |     |       | * |   |      |
|                     |      |        |     |       | * |   |      |
|                     |      |        |     |       |   |   |      |
|                     |      |        |     |       | * |   |      |
|                     |      |        |     |       | * |   |      |
|                     |      |        |     |       | 2 |   |      |
|                     |      |        |     |       | 0 |   |      |
|                     |      |        |     |       | 0 |   |      |
|                     |      |        |     |       | 6 |   |      |
|                     |      |        |     |       | 2 |   |      |
|                     |      |        |     |       | 0 |   |      |
|                     |      |        |     |       | 0 |   |      |
|                     |      |        |     |       | 7 |   |      |
|                     |      |        |     |       | * |   |      |
|                     |      |        |     |       | * |   |      |
+---------------------+------+--------+-----+-------+---+---+------+
|                     | **   | **If   |     |       |   |   |      |
|                     | H=Ho | Ho     |     |       |   |   |      |
|                     | spit | spital |     |       |   |   |      |
|                     | al** | enter  |     |       |   |   |      |
|                     |      | appl   |     |       |   |   |      |
|                     | **G  | icable |     |       |   |   |      |
|                     | =Gro | c      |     |       |   |   |      |
|                     | up** | odes** |     |       |   |   |      |
|                     |      |        |     |       |   |   |      |
|                     | **O  | **(see |     |       |   |   |      |
|                     | =Oth | ab     |     |       |   |   |      |
|                     | er** | ove)** |     |       |   |   |      |
+---------------------+------+--------+-----+-------+---+---+------+
|                     |      |        |     |       |   |   |      |
+---------------------+------+--------+-----+-------+---+---+------+
|                     |      |        |     |       |   |   |      |
+---------------------+------+--------+-----+-------+---+---+------+
|                     |      |        |     |       |   |   |      |
+---------------------+------+--------+-----+-------+---+---+------+
|                     |      |        |     |       |   |   |      |
+---------------------+------+--------+-----+-------+---+---+------+
|                     |      |        |     |       |   |   |      |
+---------------------+------+--------+-----+-------+---+---+------+

+--------+---+--------------------------------------------------------+
| **P    |   |                                                        |
| artici |   |                                                        |
| pating |   |                                                        |
| Phys   |   |                                                        |
| icians |   |                                                        |
| Sample |   |                                                        |
| Table  |   |                                                        |
| 3A**   |   |                                                        |
+--------+---+--------------------------------------------------------+
|        |   |                                                        |
+--------+---+--------------------------------------------------------+
| **D    |   |                                                        |
| irecti |   |                                                        |
| ons:** |   |                                                        |
+--------+---+--------------------------------------------------------+
| **Col  | * | **Group by component/affiliate with which physician is |
| umn:** | * | affiliated. If a physician is affiliated with multiple |
|        | ( | components, list him/her only with primary             |
|        | 1 | component.**                                           |
|        | ) |                                                        |
|        | * | **List all physicians who will participate in your     |
|        | * | CCOP, then indicate:**                                 |
|        |   |                                                        |
|        | * | **Type of practice: Group=G; Solo=S; or Hospital-Based |
|        | * | =H.**                                                  |
|        | ( |                                                        |
|        | 2 | Type of participation: enter \"A\" if the physician is |
|        | ) | expected to enter patients on NCI-approved clinical    |
|        | * | trials or \"B\" if the physician will be aware of      |
|        | * | trial requirements and actively support the CCOP but   |
|        |   | will not be actually registering patients (e.g., a     |
|        | * | pathologist or a diagnostic radiologist).              |
|        | * |                                                        |
|        | ( | Physician\'s year of graduation from medical school.   |
|        | 3 |                                                        |
|        | ) | Physician\'s specialty/subspecialty.                   |
|        | * |                                                        |
|        | * | **Indicate whether physician is board-certified or     |
|        |   | board-eligible for specialty.**                        |
|        | * |                                                        |
|        | * |                                                        |
|        | ( |                                                        |
|        | 4 |                                                        |
|        | ) |                                                        |
|        | * |                                                        |
|        | * |                                                        |
|        |   |                                                        |
|        | * |                                                        |
|        | * |                                                        |
|        | ( |                                                        |
|        | 5 |                                                        |
|        | * |                                                        |
|        | * |                                                        |
|        |   |                                                        |
|        | * |                                                        |
|        | * |                                                        |
|        | ( |                                                        |
|        | 6 |                                                        |
|        | ) |                                                        |
|        | * |                                                        |
|        | * |                                                        |
|        |   |                                                        |
|        | * |                                                        |
|        | * |                                                        |
|        | ( |                                                        |
|        | 7 |                                                        |
|        | ) |                                                        |
|        | * |                                                        |
|        | * |                                                        |
+--------+---+--------------------------------------------------------+

+-------------+-------------+------+-----+-----+--------+-----+-----+
| **(1)**     | **(2)**     | **(  | *   | *   | *      | *   |     |
|             |             | 3)** | *(4 | *(5 | *(6)** | *(7 |     |
| **C         | **Phy       |      | )** | )** |        | )** |     |
| omponent/** | sician\'s** | **Pr |     |     | **     |     |     |
|             |             | acti | **  | **G | Specia | **B |     |
| **          | **Full      | ce** | Typ | rad | lty/** | oar |     |
| Affiliate** | Name**      |      | e** | .** |        | d** |     |
|             |             | **Ty |     |     | **Su   |     |     |
|             |             | pe** | **A | **  | bspeci |     |     |
|             |             |      | or  | Yea | alty** |     |     |
|             |             | *    | B** | r** |        |     |     |
|             |             | *G/S |     |     |        |     |     |
|             |             | /H** |     |     |        |     |     |
+-------------+-------------+------+-----+-----+--------+-----+-----+
|             |             |      |     |     |        | **C | **E |
|             |             |      |     |     |        | ert | lig |
|             |             |      |     |     |        | .** | ibl |
|             |             |      |     |     |        |     | e** |
+-------------+-------------+------+-----+-----+--------+-----+-----+
|             |             |      |     |     |        |     |     |
+-------------+-------------+------+-----+-----+--------+-----+-----+
|             |             |      |     |     |        |     |     |
+-------------+-------------+------+-----+-----+--------+-----+-----+
|             |             |      |     |     |        |     |     |
+-------------+-------------+------+-----+-----+--------+-----+-----+
|             |             |      |     |     |        |     |     |
+-------------+-------------+------+-----+-----+--------+-----+-----+
|             |             |      |     |     |        |     |     |
+-------------+-------------+------+-----+-----+--------+-----+-----+
|             |             |      |     |     |        |     |     |
+-------------+-------------+------+-----+-----+--------+-----+-----+
|             |             |      |     |     |        |     |     |
+-------------+-------------+------+-----+-----+--------+-----+-----+
|             |             |      |     |     |        |     |     |
+-------------+-------------+------+-----+-----+--------+-----+-----+
|             |             |      |     |     |        |     |     |
+-------------+-------------+------+-----+-----+--------+-----+-----+
|             |             |      |     |     |        |     |     |
+-------------+-------------+------+-----+-----+--------+-----+-----+

+------+---+-------------------------------------------+--------------+
| **N  |   |                                           | **Sample     |
| on-P |   |                                           | Table 3B**   |
| hysi |   |                                           |              |
| cian |   |                                           |              |
| I    |   |                                           |              |
| nves |   |                                           |              |
| tiga |   |                                           |              |
| tors |   |                                           |              |
| Res  |   |                                           |              |
| pons |   |                                           |              |
| ible |   |                                           |              |
| for  |   |                                           |              |
| Ente |   |                                           |              |
| ring |   |                                           |              |
| Part |   |                                           |              |
| icip |   |                                           |              |
| ants |   |                                           |              |
| on   |   |                                           |              |
| Stu  |   |                                           |              |
| dy** |   |                                           |              |
+------+---+-------------------------------------------+--------------+
|      |   |                                           |              |
+------+---+-------------------------------------------+--------------+
| **D  |   |                                           |              |
| irec |   |                                           |              |
| tion |   |                                           |              |
| s:** |   |                                           |              |
+------+---+-------------------------------------------+--------------+
| **C  | * | **Group by component/affiliate with which |              |
| olum | * | individual is affiliated. If an           |              |
| n:** | ( | individual is affiliated with multiple    |              |
|      | 1 | components, list him/her only with        |              |
|      | ) | primary component.**                      |              |
|      | * |                                           |              |
|      | * | **List all non-physician investigators    |              |
|      |   | responsible for patients/participants on  |              |
|      | * | cancer prevention and control trials in   |              |
|      | * | your CCOP.**                              |              |
|      | ( |                                           |              |
|      | 2 | **List highest degree attained.**         |              |
|      | ) |                                           |              |
|      | * | **Enter the year the highest degree was   |              |
|      | * | confirmed.**                              |              |
|      |   |                                           |              |
|      | * | **Individual\'s specialty/discipline.**   |              |
|      | * |                                           |              |
|      | ( |                                           |              |
|      | 3 |                                           |              |
|      | ) |                                           |              |
|      | * |                                           |              |
|      | * |                                           |              |
|      |   |                                           |              |
|      | * |                                           |              |
|      | * |                                           |              |
|      | ( |                                           |              |
|      | 4 |                                           |              |
|      | ) |                                           |              |
|      | * |                                           |              |
|      | * |                                           |              |
|      |   |                                           |              |
|      | * |                                           |              |
|      | * |                                           |              |
|      | ( |                                           |              |
|      | 5 |                                           |              |
|      | ) |                                           |              |
|      | * |                                           |              |
|      | * |                                           |              |
+------+---+-------------------------------------------+--------------+

+------------------+------------------------+-------+--------+--------+
| **(1)**          | **(2)**                | **    | *      | *      |
|                  |                        | (3)** | *(4)** | *(5)** |
| **Component/**   | **Individual\'s**      |       |        |        |
|                  |                        | *     | **Year | **     |
| **Affiliate**    | **Full Name**          | *High | De     | Specia |
|                  |                        | est** | gree** | lty/** |
|                  |                        |       |        |        |
|                  |                        | **Deg | *      | **     |
|                  |                        | ree** | *Confi | Discip |
|                  |                        |       | rmed** | line** |
+------------------+------------------------+-------+--------+--------+
|                  |                        |       |        |        |
+------------------+------------------------+-------+--------+--------+
|                  |                        |       |        |        |
+------------------+------------------------+-------+--------+--------+
|                  |                        |       |        |        |
+------------------+------------------------+-------+--------+--------+
|                  |                        |       |        |        |
+------------------+------------------------+-------+--------+--------+
|                  |                        |       |        |        |
+------------------+------------------------+-------+--------+--------+
|                  |                        |       |        |        |
+------------------+------------------------+-------+--------+--------+
|                  |                        |       |        |        |
+------------------+------------------------+-------+--------+--------+
|                  |                        |       |        |        |
+------------------+------------------------+-------+--------+--------+
|                  |                        |       |        |        |
+------------------+------------------------+-------+--------+--------+
|                  |                        |       |        |        |
+------------------+------------------------+-------+--------+--------+
|                  |                        |       |        |        |
+------------------+------------------------+-------+--------+--------+
|                  |                        |       |        |        |
+------------------+------------------------+-------+--------+--------+
|                  |                        |       |        |        |
+------------------+------------------------+-------+--------+--------+
|                  |                        |       |        |        |
+------------------+------------------------+-------+--------+--------+
|                  |                        |       |        |        |
+------------------+------------------------+-------+--------+--------+

+-----------------+----------------------------------------------------+
| **All Other     | **Sample Table 4**                                 |
| Personnel**     |                                                    |
+-----------------+----------------------------------------------------+
|                 |                                                    |
+-----------------+----------------------------------------------------+
| **Directions:** | > **List all personnel (e.g., CCOP                 |
|                 | > administrator/coordinator, clinical research     |
|                 | > associates, data managers, nurses) who will      |
|                 | > participate in the CCOP activities. Indicate     |
|                 | > CCOP component/affiliate with which person is    |
|                 | > most closely associated. Please complete all     |
|                 | > columns.**                                       |
+-----------------+----------------------------------------------------+

+----------------+------------------+----+-------+------+------------+
| **(1)**        | **(2)**          | *  | **    | **(  | **(6)**    |
|                |                  | *( | (4)** | 5)** |            |
| **Compone      | **Individual's** | 3) |       |      | **         |
| nt/Affiliate** |                  | ** | *     | **Po | Proposed** |
|                | **Full Name**    |    | *High | siti |            |
|                |                  | *  | est** | on** | **Hrs/Week |
|                |                  | *C |       |      | on**       |
|                |                  | he | **    |      |            |
|                |                  | ck | Acade |      | **CCOP     |
|                |                  | ** | mic** |      | Ac         |
|                |                  |    |       |      | tivities** |
|                |                  | ** | **Deg |      |            |
|                |                  | if | ree** |      |            |
|                |                  | ** |       |      |            |
|                |                  |    |       |      |            |
|                |                  | ** |       |      |            |
|                |                  | R. |       |      |            |
|                |                  | N. |       |      |            |
|                |                  | ** |       |      |            |
+================+==================+====+=======+======+============+
|                |                  |    |       |      |            |
+----------------+------------------+----+-------+------+------------+
|                |                  |    |       |      |            |
+----------------+------------------+----+-------+------+------------+
|                |                  |    |       |      |            |
+----------------+------------------+----+-------+------+------------+
|                |                  |    |       |      |            |
+----------------+------------------+----+-------+------+------------+
|                |                  |    |       |      |            |
+----------------+------------------+----+-------+------+------------+
|                |                  |    |       |      |            |
+----------------+------------------+----+-------+------+------------+
|                |                  |    |       |      |            |
+----------------+------------------+----+-------+------+------------+
|                |                  |    |       |      |            |
+----------------+------------------+----+-------+------+------------+
|                |                  |    |       |      |            |
+----------------+------------------+----+-------+------+------------+
|                |                  |    |       |      |            |
+----------------+------------------+----+-------+------+------------+
|                |                  |    |       |      |            |
+----------------+------------------+----+-------+------+------------+
|                |                  |    |       |      |            |
+----------------+------------------+----+-------+------+------------+

+---+-------------+----+----+----+--------------------------+-----+---+---+
| * |             |    |    |    |                          |     |   |   |
| * |             |    |    |    |                          |     |   |   |
| N |             |    |    |    |                          |     |   |   |
| u |             |    |    |    |                          |     |   |   |
| m |             |    |    |    |                          |     |   |   |
| b |             |    |    |    |                          |     |   |   |
| e |             |    |    |    |                          |     |   |   |
| r |             |    |    |    |                          |     |   |   |
| o |             |    |    |    |                          |     |   |   |
| f |             |    |    |    |                          |     |   |   |
| N |             |    |    |    |                          |     |   |   |
| e |             |    |    |    |                          |     |   |   |
| w |             |    |    |    |                          |     |   |   |
| l |             |    |    |    |                          |     |   |   |
| y |             |    |    |    |                          |     |   |   |
| D |             |    |    |    |                          |     |   |   |
| i |             |    |    |    |                          |     |   |   |
| a |             |    |    |    |                          |     |   |   |
| g |             |    |    |    |                          |     |   |   |
| n |             |    |    |    |                          |     |   |   |
| o |             |    |    |    |                          |     |   |   |
| s |             |    |    |    |                          |     |   |   |
| e |             |    |    |    |                          |     |   |   |
| d |             |    |    |    |                          |     |   |   |
| C |             |    |    |    |                          |     |   |   |
| a |             |    |    |    |                          |     |   |   |
| n |             |    |    |    |                          |     |   |   |
| c |             |    |    |    |                          |     |   |   |
| e |             |    |    |    |                          |     |   |   |
| r |             |    |    |    |                          |     |   |   |
| P |             |    |    |    |                          |     |   |   |
| a |             |    |    |    |                          |     |   |   |
| t |             |    |    |    |                          |     |   |   |
| i |             |    |    |    |                          |     |   |   |
| e |             |    |    |    |                          |     |   |   |
| n |             |    |    |    |                          |     |   |   |
| t |             |    |    |    |                          |     |   |   |
| s |             |    |    |    |                          |     |   |   |
| B |             |    |    |    |                          |     |   |   |
| y |             |    |    |    |                          |     |   |   |
| S |             |    |    |    |                          |     |   |   |
| i |             |    |    |    |                          |     |   |   |
| t |             |    |    |    |                          |     |   |   |
| e |             |    |    |    |                          |     |   |   |
| S |             |    |    |    |                          |     |   |   |
| a |             |    |    |    |                          |     |   |   |
| m |             |    |    |    |                          |     |   |   |
| p |             |    |    |    |                          |     |   |   |
| l |             |    |    |    |                          |     |   |   |
| e |             |    |    |    |                          |     |   |   |
| T |             |    |    |    |                          |     |   |   |
| a |             |    |    |    |                          |     |   |   |
| b |             |    |    |    |                          |     |   |   |
| l |             |    |    |    |                          |     |   |   |
| e |             |    |    |    |                          |     |   |   |
| 5 |             |    |    |    |                          |     |   |   |
| * |             |    |    |    |                          |     |   |   |
| * |             |    |    |    |                          |     |   |   |
+---+-------------+----+----+----+--------------------------+-----+---+---+
|   |             |    |    |    |                          |     |   |   |
+---+-------------+----+----+----+--------------------------+-----+---+---+
| * |             | >  |    |    |                          |     |   |   |
| * |             |  * |    |    |                          |     |   |   |
| D |             | *P |    |    |                          |     |   |   |
| i |             | ro |    |    |                          |     |   |   |
| r |             | vi |    |    |                          |     |   |   |
| e |             | de |    |    |                          |     |   |   |
| c |             | >  |    |    |                          |     |   |   |
| t |             |  f |    |    |                          |     |   |   |
| i |             | ig |    |    |                          |     |   |   |
| o |             | ur |    |    |                          |     |   |   |
| n |             | es |    |    |                          |     |   |   |
| s |             | >  |    |    |                          |     |   |   |
| : |             |  f |    |    |                          |     |   |   |
| * |             | or |    |    |                          |     |   |   |
| * |             | >  |    |    |                          |     |   |   |
|   |             |  t |    |    |                          |     |   |   |
|   |             | he |    |    |                          |     |   |   |
|   |             | >  |    |    |                          |     |   |   |
|   |             |  t |    |    |                          |     |   |   |
|   |             | ab |    |    |                          |     |   |   |
|   |             | le |    |    |                          |     |   |   |
|   |             | >  |    |    |                          |     |   |   |
|   |             |  b |    |    |                          |     |   |   |
|   |             | el |    |    |                          |     |   |   |
|   |             | ow |    |    |                          |     |   |   |
|   |             | >  |    |    |                          |     |   |   |
|   |             | to |    |    |                          |     |   |   |
|   |             | >  |    |    |                          |     |   |   |
|   |             |  t |    |    |                          |     |   |   |
|   |             | he |    |    |                          |     |   |   |
|   |             | >  |    |    |                          |     |   |   |
|   |             | ex |    |    |                          |     |   |   |
|   |             | te |    |    |                          |     |   |   |
|   |             | nt |    |    |                          |     |   |   |
|   |             | >  |    |    |                          |     |   |   |
|   |             |  p |    |    |                          |     |   |   |
|   |             | os |    |    |                          |     |   |   |
|   |             | si |    |    |                          |     |   |   |
|   |             | bl |    |    |                          |     |   |   |
|   |             | e. |    |    |                          |     |   |   |
|   |             | >  |    |    |                          |     |   |   |
|   |             |  U |    |    |                          |     |   |   |
|   |             | se |    |    |                          |     |   |   |
|   |             | >  |    |    |                          |     |   |   |
|   |             |  n |    |    |                          |     |   |   |
|   |             | ew |    |    |                          |     |   |   |
|   |             | >  |    |    |                          |     |   |   |
|   |             |  c |    |    |                          |     |   |   |
|   |             | as |    |    |                          |     |   |   |
|   |             | es |    |    |                          |     |   |   |
|   |             | >  |    |    |                          |     |   |   |
|   |             |  d |    |    |                          |     |   |   |
|   |             | ia |    |    |                          |     |   |   |
|   |             | gn |    |    |                          |     |   |   |
|   |             | os |    |    |                          |     |   |   |
|   |             | ed |    |    |                          |     |   |   |
|   |             | >  |    |    |                          |     |   |   |
|   |             | or |    |    |                          |     |   |   |
|   |             | >  |    |    |                          |     |   |   |
|   |             |  r |    |    |                          |     |   |   |
|   |             | ec |    |    |                          |     |   |   |
|   |             | ei |    |    |                          |     |   |   |
|   |             | vi |    |    |                          |     |   |   |
|   |             | ng |    |    |                          |     |   |   |
|   |             | >  |    |    |                          |     |   |   |
|   |             |  t |    |    |                          |     |   |   |
|   |             | re |    |    |                          |     |   |   |
|   |             | at |    |    |                          |     |   |   |
|   |             | me |    |    |                          |     |   |   |
|   |             | nt |    |    |                          |     |   |   |
|   |             | >  |    |    |                          |     |   |   |
|   |             | at |    |    |                          |     |   |   |
|   |             | >  |    |    |                          |     |   |   |
|   |             | th |    |    |                          |     |   |   |
|   |             | at |    |    |                          |     |   |   |
|   |             | >  |    |    |                          |     |   |   |
|   |             |  h |    |    |                          |     |   |   |
|   |             | os |    |    |                          |     |   |   |
|   |             | pi |    |    |                          |     |   |   |
|   |             | ta |    |    |                          |     |   |   |
|   |             | l, |    |    |                          |     |   |   |
|   |             | >  |    |    |                          |     |   |   |
|   |             | ex |    |    |                          |     |   |   |
|   |             | ce |    |    |                          |     |   |   |
|   |             | pt |    |    |                          |     |   |   |
|   |             | >  |    |    |                          |     |   |   |
|   |             |  f |    |    |                          |     |   |   |
|   |             | or |    |    |                          |     |   |   |
|   |             | >  |    |    |                          |     |   |   |
|   |             |  b |    |    |                          |     |   |   |
|   |             | as |    |    |                          |     |   |   |
|   |             | al |    |    |                          |     |   |   |
|   |             | >  |    |    |                          |     |   |   |
|   |             | ce |    |    |                          |     |   |   |
|   |             | ll |    |    |                          |     |   |   |
|   |             | >  |    |    |                          |     |   |   |
|   |             | or |    |    |                          |     |   |   |
|   |             | >  |    |    |                          |     |   |   |
|   |             | sq |    |    |                          |     |   |   |
|   |             | ua |    |    |                          |     |   |   |
|   |             | mo |    |    |                          |     |   |   |
|   |             | us |    |    |                          |     |   |   |
|   |             | >  |    |    |                          |     |   |   |
|   |             | ce |    |    |                          |     |   |   |
|   |             | ll |    |    |                          |     |   |   |
|   |             | >  |    |    |                          |     |   |   |
|   |             |  c |    |    |                          |     |   |   |
|   |             | ar |    |    |                          |     |   |   |
|   |             | ci |    |    |                          |     |   |   |
|   |             | no |    |    |                          |     |   |   |
|   |             | ma |    |    |                          |     |   |   |
|   |             | >  |    |    |                          |     |   |   |
|   |             | of |    |    |                          |     |   |   |
|   |             | >  |    |    |                          |     |   |   |
|   |             |  t |    |    |                          |     |   |   |
|   |             | he |    |    |                          |     |   |   |
|   |             | >  |    |    |                          |     |   |   |
|   |             |  s |    |    |                          |     |   |   |
|   |             | ki |    |    |                          |     |   |   |
|   |             | n. |    |    |                          |     |   |   |
|   |             | >  |    |    |                          |     |   |   |
|   |             | Su |    |    |                          |     |   |   |
|   |             | bm |    |    |                          |     |   |   |
|   |             | it |    |    |                          |     |   |   |
|   |             | >  |    |    |                          |     |   |   |
|   |             |  a |    |    |                          |     |   |   |
|   |             | >  |    |    |                          |     |   |   |
|   |             | se |    |    |                          |     |   |   |
|   |             | pa |    |    |                          |     |   |   |
|   |             | ra |    |    |                          |     |   |   |
|   |             | te |    |    |                          |     |   |   |
|   |             | >  |    |    |                          |     |   |   |
|   |             |  s |    |    |                          |     |   |   |
|   |             | he |    |    |                          |     |   |   |
|   |             | et |    |    |                          |     |   |   |
|   |             | >  |    |    |                          |     |   |   |
|   |             |  f |    |    |                          |     |   |   |
|   |             | or |    |    |                          |     |   |   |
|   |             | >  |    |    |                          |     |   |   |
|   |             | ea |    |    |                          |     |   |   |
|   |             | ch |    |    |                          |     |   |   |
|   |             | >  |    |    |                          |     |   |   |
|   |             | ho |    |    |                          |     |   |   |
|   |             | sp |    |    |                          |     |   |   |
|   |             | it |    |    |                          |     |   |   |
|   |             | al |    |    |                          |     |   |   |
|   |             | >  |    |    |                          |     |   |   |
|   |             | co |    |    |                          |     |   |   |
|   |             | mp |    |    |                          |     |   |   |
|   |             | on |    |    |                          |     |   |   |
|   |             | en |    |    |                          |     |   |   |
|   |             | t. |    |    |                          |     |   |   |
|   |             | ** |    |    |                          |     |   |   |
+---+-------------+----+----+----+--------------------------+-----+---+---+
| * |             | ** |    |    |                          |     |   |   |
| * |             | [\ |    |    |                          |     |   |   |
| N |             | _\ |    |    |                          |     |   |   |
| a |             | _\ |    |    |                          |     |   |   |
| m |             | _\ |    |    |                          |     |   |   |
| e |             | _\ |    |    |                          |     |   |   |
| o |             | _\ |    |    |                          |     |   |   |
| f |             | _\ |    |    |                          |     |   |   |
| C |             | _\ |    |    |                          |     |   |   |
| o |             | _\ |    |    |                          |     |   |   |
| m |             | _\ |    |    |                          |     |   |   |
| p |             | _\ |    |    |                          |     |   |   |
| o |             | _\ |    |    |                          |     |   |   |
| n |             | _\ |    |    |                          |     |   |   |
| e |             | _\ |    |    |                          |     |   |   |
| n |             | _\ |    |    |                          |     |   |   |
| t |             | _\ |    |    |                          |     |   |   |
| : |             | _\ |    |    |                          |     |   |   |
| * |             | _\ |    |    |                          |     |   |   |
| * |             | _\ |    |    |                          |     |   |   |
|   |             | _\ |    |    |                          |     |   |   |
|   |             | _\ |    |    |                          |     |   |   |
|   |             | _\ |    |    |                          |     |   |   |
|   |             | _\ |    |    |                          |     |   |   |
|   |             | _\ |    |    |                          |     |   |   |
|   |             | _\ |    |    |                          |     |   |   |
|   |             | _\ |    |    |                          |     |   |   |
|   |             | _\ |    |    |                          |     |   |   |
|   |             | _\ |    |    |                          |     |   |   |
|   |             | _\ |    |    |                          |     |   |   |
|   |             | _\ |    |    |                          |     |   |   |
|   |             | _\ |    |    |                          |     |   |   |
|   |             | _\ |    |    |                          |     |   |   |
|   |             | _\ |    |    |                          |     |   |   |
|   |             | _\ |    |    |                          |     |   |   |
|   |             | _\ |    |    |                          |     |   |   |
|   |             | _\ |    |    |                          |     |   |   |
|   |             | _\ |    |    |                          |     |   |   |
|   |             | _\ |    |    |                          |     |   |   |
|   |             | _\ |    |    |                          |     |   |   |
|   |             | _\ |    |    |                          |     |   |   |
|   |             | _\ |    |    |                          |     |   |   |
|   |             | _\ |    |    |                          |     |   |   |
|   |             | _\ |    |    |                          |     |   |   |
|   |             | _\ |    |    |                          |     |   |   |
|   |             | _\ |    |    |                          |     |   |   |
|   |             | _\ |    |    |                          |     |   |   |
|   |             | _\ |    |    |                          |     |   |   |
|   |             | _\ |    |    |                          |     |   |   |
|   |             | _\ |    |    |                          |     |   |   |
|   |             | _\ |    |    |                          |     |   |   |
|   |             | _\ |    |    |                          |     |   |   |
|   |             | _\ |    |    |                          |     |   |   |
|   |             | _\ |    |    |                          |     |   |   |
|   |             | _\ |    |    |                          |     |   |   |
|   |             | _\ |    |    |                          |     |   |   |
|   |             | _\ |    |    |                          |     |   |   |
|   |             | _\ |    |    |                          |     |   |   |
|   |             | _\ |    |    |                          |     |   |   |
|   |             | _\ |    |    |                          |     |   |   |
|   |             | _\ |    |    |                          |     |   |   |
|   |             | _\ |    |    |                          |     |   |   |
|   |             | _\ |    |    |                          |     |   |   |
|   |             | _\ |    |    |                          |     |   |   |
|   |             | _\ |    |    |                          |     |   |   |
|   |             | _\ |    |    |                          |     |   |   |
|   |             | _\ |    |    |                          |     |   |   |
|   |             | _\ |    |    |                          |     |   |   |
|   |             | _\ |    |    |                          |     |   |   |
|   |             | _\ |    |    |                          |     |   |   |
|   |             | _\ |    |    |                          |     |   |   |
|   |             | _\ |    |    |                          |     |   |   |
|   |             | _\ |    |    |                          |     |   |   |
|   |             | _\ |    |    |                          |     |   |   |
|   |             | _\ |    |    |                          |     |   |   |
|   |             | _\ |    |    |                          |     |   |   |
|   |             | _] |    |    |                          |     |   |   |
|   |             | {. |    |    |                          |     |   |   |
|   |             | un |    |    |                          |     |   |   |
|   |             | de |    |    |                          |     |   |   |
|   |             | rl |    |    |                          |     |   |   |
|   |             | in |    |    |                          |     |   |   |
|   |             | e} |    |    |                          |     |   |   |
|   |             | ** |    |    |                          |     |   |   |
+---+-------------+----+----+----+--------------------------+-----+---+---+
| * |             | >  |    |    |                          |     |   |   |
| * |             | >  |    |    |                          |     |   |   |
| I |             | ** |    |    |                          |     |   |   |
| n |             | Ho |    |    |                          |     |   |   |
| f |             | sp |    |    |                          |     |   |   |
| o |             | it |    |    |                          |     |   |   |
| r |             | al |    |    |                          |     |   |   |
| m |             | >  |    |    |                          |     |   |   |
| a |             | Re |    |    |                          |     |   |   |
| t |             | gi |    |    |                          |     |   |   |
| i |             | st |    |    |                          |     |   |   |
| o |             | ry |    |    |                          |     |   |   |
| n |             | ** |    |    |                          |     |   |   |
| S |             | >  |    |    |                          |     |   |   |
| o |             | ** |    |    |                          |     |   |   |
| u |             | Re |    |    |                          |     |   |   |
| r |             | gi |    |    |                          |     |   |   |
| c |             | on |    |    |                          |     |   |   |
| e |             | al |    |    |                          |     |   |   |
| : |             | >  |    |    |                          |     |   |   |
| * |             | Re |    |    |                          |     |   |   |
| * |             | gi |    |    |                          |     |   |   |
|   |             | st |    |    |                          |     |   |   |
|   |             | ry |    |    |                          |     |   |   |
|   |             | ** |    |    |                          |     |   |   |
|   |             | >  |    |    |                          |     |   |   |
|   |             | ** |    |    |                          |     |   |   |
|   |             | Po |    |    |                          |     |   |   |
|   |             | pu |    |    |                          |     |   |   |
|   |             | la |    |    |                          |     |   |   |
|   |             | ti |    |    |                          |     |   |   |
|   |             | on |    |    |                          |     |   |   |
|   |             | >  |    |    |                          |     |   |   |
|   |             |  B |    |    |                          |     |   |   |
|   |             | as |    |    |                          |     |   |   |
|   |             | ed |    |    |                          |     |   |   |
|   |             | >  |    |    |                          |     |   |   |
|   |             | Re |    |    |                          |     |   |   |
|   |             | gi |    |    |                          |     |   |   |
|   |             | st |    |    |                          |     |   |   |
|   |             | ry |    |    |                          |     |   |   |
|   |             | ** |    |    |                          |     |   |   |
|   |             | >  |    |    |                          |     |   |   |
|   |             | >  |    |    |                          |     |   |   |
|   |             | ** |    |    |                          |     |   |   |
|   |             | Ho |    |    |                          |     |   |   |
|   |             | sp |    |    |                          |     |   |   |
|   |             | it |    |    |                          |     |   |   |
|   |             | al |    |    |                          |     |   |   |
|   |             | >  |    |    |                          |     |   |   |
|   |             |  D |    |    |                          |     |   |   |
|   |             | is |    |    |                          |     |   |   |
|   |             | ch |    |    |                          |     |   |   |
|   |             | ar |    |    |                          |     |   |   |
|   |             | ge |    |    |                          |     |   |   |
|   |             | >  |    |    |                          |     |   |   |
|   |             | Da |    |    |                          |     |   |   |
|   |             | ta |    |    |                          |     |   |   |
|   |             | ** |    |    |                          |     |   |   |
|   |             | >  |    |    |                          |     |   |   |
|   |             |  * |    |    |                          |     |   |   |
|   |             | *O |    |    |                          |     |   |   |
|   |             | th |    |    |                          |     |   |   |
|   |             | er |    |    |                          |     |   |   |
|   |             | ** |    |    |                          |     |   |   |
+---+-------------+----+----+----+--------------------------+-----+---+---+
|   |             |    |    |    |                          |     |   |   |
+---+-------------+----+----+----+--------------------------+-----+---+---+
|   |             |    | ** |    |                          | *   |   |   |
|   |             |    | Ca |    |                          | *Ca |   |   |
|   |             |    | le |    |                          | len |   |   |
|   |             |    | nd |    |                          | dar |   |   |
|   |             |    | ar |    |                          | Yea |   |   |
|   |             |    | Ye |    |                          | r** |   |   |
|   |             |    | ar |    |                          |     |   |   |
|   |             |    | ** |    |                          | **2 |   |   |
|   |             |    |    |    |                          | 006 |   |   |
|   |             |    | ** |    |                          | 200 |   |   |
|   |             |    | 20 |    |                          | 7** |   |   |
|   |             |    | 06 |    |                          |     |   |   |
|   |             |    | 20 |    |                          |     |   |   |
|   |             |    | 07 |    |                          |     |   |   |
|   |             |    | ** |    |                          |     |   |   |
+---+-------------+----+----+----+--------------------------+-----+---+---+
|   | **Breast    |    |    |    | **Non-Small Cell Lung**  |     |   |   |
|   | Tumor**     |    |    |    |                          |     |   |   |
+---+-------------+----+----+----+--------------------------+-----+---+---+
|   | **          |    |    |    | **Hodgkin=s Disease**    |     |   |   |
|   | Esophagus** |    |    |    |                          |     |   |   |
+---+-------------+----+----+----+--------------------------+-----+---+---+
|   | **Stomach** |    |    |    | **Non-Hodgkin=s          |     |   |   |
|   |             |    |    |    | Disease**                |     |   |   |
+---+-------------+----+----+----+--------------------------+-----+---+---+
|   | *           |    |    |    | **Kaposi=s Sarcoma**     |     |   |   |
|   | *Pancreas** |    |    |    |                          |     |   |   |
+---+-------------+----+----+----+--------------------------+-----+---+---+
|   | **Hepa      |    |    |    | **Melanoma**             |     |   |   |
|   | tobiliary** |    |    |    |                          |     |   |   |
+---+-------------+----+----+----+--------------------------+-----+---+---+
|   | **Colon**   |    |    |    | **Head/Neck Tumors**     |     |   |   |
+---+-------------+----+----+----+--------------------------+-----+---+---+
|   | **Rectum**  |    |    |    | **Brain/Other CNS        |     |   |   |
|   |             |    |    |    | Tumors**                 |     |   |   |
+---+-------------+----+----+----+--------------------------+-----+---+---+
|   | **GI        |    |    |    | **Endocrine**            |     |   |   |
|   | (other)**   |    |    |    |                          |     |   |   |
+---+-------------+----+----+----+--------------------------+-----+---+---+
|   | **Bladder** |    |    |    | **Osteogenic Sarcoma**   |     |   |   |
+---+-------------+----+----+----+--------------------------+-----+---+---+
|   | **Kidney**  |    |    |    | **Soft Tissue Sarcoma**  |     |   |   |
+---+-------------+----+----+----+--------------------------+-----+---+---+
|   | *           |    |    |    | **Rhabdomyosaracoma**    |     |   |   |
|   | *Prostate** |    |    |    |                          |     |   |   |
+---+-------------+----+----+----+--------------------------+-----+---+---+
|   | **Testis**  |    |    |    | **Ewing=s Sarcoma**      |     |   |   |
+---+-------------+----+----+----+--------------------------+-----+---+---+
|   | **GU        |    |    |    | **Sarcoma (other)**      |     |   |   |
|   | (other)**   |    |    |    |                          |     |   |   |
+---+-------------+----+----+----+--------------------------+-----+---+---+
|   | **Cervix**  |    |    |    | **Wilm=s Tumor**         |     |   |   |
+---+-------------+----+----+----+--------------------------+-----+---+---+
|   | **Ovary**   |    |    |    | **Neuroblastoma**        |     |   |   |
+---+-------------+----+----+----+--------------------------+-----+---+---+
|   | **Uterus,   |    |    |    | **Pediatric ALL**        |     |   |   |
|   | En          |    |    |    |                          |     |   |   |
|   | dometrial** |    |    |    |                          |     |   |   |
+---+-------------+----+----+----+--------------------------+-----+---+---+
|   | **GYN       |    |    |    | **Pediatric AML**        |     |   |   |
|   | (other)**   |    |    |    |                          |     |   |   |
+---+-------------+----+----+----+--------------------------+-----+---+---+
|   | **Myeloma** |    |    |    | **Pediatric Acute        |     |   |   |
|   |             |    |    |    | Leukemia (other)**       |     |   |   |
+---+-------------+----+----+----+--------------------------+-----+---+---+
|   | **Adult     |    |    |    | **Pediatric Lymphomas    |     |   |   |
|   | Acute       |    |    |    | incl. Hodgkin=s          |     |   |   |
|   | Lymphocytic |    |    |    | Disease**                |     |   |   |
|   | Leukemia**  |    |    |    |                          |     |   |   |
+---+-------------+----+----+----+--------------------------+-----+---+---+
|   | **Adult     |    |    |    | **Pediatric Solid        |     |   |   |
|   | Acute       |    |    |    | Tumors/Others**          |     |   |   |
|   | Non-        |    |    |    |                          |     |   |   |
|   | Lymphocytic |    |    |    |                          |     |   |   |
|   | Leukemia**  |    |    |    |                          |     |   |   |
+---+-------------+----+----+----+--------------------------+-----+---+---+
|   | **Chronic   |    |    |    | **Other**                |     |   |   |
|   | Leukemia**  |    |    |    |                          |     |   |   |
+---+-------------+----+----+----+--------------------------+-----+---+---+
|   | **Small     |    |    |    |                          |     |   |   |
|   | Cell Lung** |    |    |    |                          |     |   |   |
+---+-------------+----+----+----+--------------------------+-----+---+---+

**Total:**

+------+---+-------------------------------------------+--------------+
| *    |   |                                           | **Sample     |
| *Acc |   |                                           | Table 6A**   |
| rual |   |                                           |              |
| to   |   |                                           |              |
| NCI  |   |                                           |              |
| APPR |   |                                           |              |
| OVED |   |                                           |              |
| Ca   |   |                                           |              |
| ncer |   |                                           |              |
| T    |   |                                           |              |
| reat |   |                                           |              |
| ment |   |                                           |              |
| Clin |   |                                           |              |
| ical |   |                                           |              |
| Tria |   |                                           |              |
| ls** |   |                                           |              |
+------+---+-------------------------------------------+--------------+
|      |   |                                           |              |
+------+---+-------------------------------------------+--------------+
| **D  |   |                                           |              |
| irec |   |                                           |              |
| tion |   |                                           |              |
| s:** |   |                                           |              |
+------+---+-------------------------------------------+--------------+
| **C  | * | > **Indicate if currently participating   |              |
| olum | * | > in CCOP (Yes or No).**                  |              |
| n:** | ( | >                                         |              |
|      | 1 | > **Indicate trial source: name of        |              |
|      | ) | > cooperative group or cancer center.**   |              |
|      | * | >                                         |              |
|      | * | > **Code the accrual by predominant       |              |
|      |   | > practice mode for a given year:**       |              |
|      | * | >                                         |              |
|      | * | > **private practice = P; salaried        |              |
|      | ( | > academic = A; training/fellowship =     |              |
|      | 3 | > F.**                                    |              |
|      | ) |                                           |              |
|      | * |                                           |              |
|      | * |                                           |              |
|      |   |                                           |              |
|      | * |                                           |              |
|      | * |                                           |              |
|      | ( |                                           |              |
|      | 4 |                                           |              |
|      | ) |                                           |              |
|      | * |                                           |              |
|      | * |                                           |              |
+------+---+-------------------------------------------+--------------+

> **This table is intended to reflect current entries and is not a
> substitution for the total treatment accrual in the**
>
> **progress report (if applicable). For all current and projected
> physicians, please list accrual by physician to all**
>
> **NCI-approved trials (e.g.: Cooperative Group/Cancer Center Research
> Bases).**

+----------------------------+------+-------+-------+--------+-------+
| **(1)**                    | **(  | **    | **    |        |       |
|                            | 2)** | (3)** | (4)** |        |       |
| **Names of Existing CCOP** |      |       |       |        |       |
|                            | **CC | **Tr  | **N   |        |       |
| **Physicians\* and         | OP** | ial** | umber |        |       |
| Proposed**                 |      |       | of    |        |       |
|                            | *    | **Sou | Pat   |        |       |
| **Participating            | *Phy | rce** | ients |        |       |
| Physicians**               | s.** |       | Ente  |        |       |
|                            |      |       | red** |        |       |
|                            | *    |       |       |        |       |
|                            | *(Y/ |       |       |        |       |
|                            | N)** |       |       |        |       |
+----------------------------+------+-------+-------+--------+-------+
|                            |      |       | **6   | *      | **6   |
|                            |      |       | /05-5 | *6/06- | /07-5 |
|                            |      |       | /06** | 5/07** | /08** |
+----------------------------+------+-------+-------+--------+-------+
| **Example: Jane R. Doe,    | *    | **NS  | **    | **     | **2   |
| MD**                       | *Y** | ABP** | 0/F** | 13/F** | 0/A** |
+----------------------------+------+-------+-------+--------+-------+
|                            |      |       |       |        |       |
+----------------------------+------+-------+-------+--------+-------+
|                            |      |       |       |        |       |
+----------------------------+------+-------+-------+--------+-------+
|                            |      |       |       |        |       |
+----------------------------+------+-------+-------+--------+-------+
|                            |      |       |       |        |       |
+----------------------------+------+-------+-------+--------+-------+
|                            |      |       |       |        |       |
+----------------------------+------+-------+-------+--------+-------+
|                            |      |       |       |        |       |
+----------------------------+------+-------+-------+--------+-------+
|                            |      |       |       |        |       |
+----------------------------+------+-------+-------+--------+-------+
|                            |      |       |       |        |       |
+----------------------------+------+-------+-------+--------+-------+
|                            |      |       |       |        |       |
+----------------------------+------+-------+-------+--------+-------+
|                            |      |       |       |        |       |
+----------------------------+------+-------+-------+--------+-------+
|                            |      |       |       |        |       |
+----------------------------+------+-------+-------+--------+-------+
|                            |      |       |       |        |       |
+----------------------------+------+-------+-------+--------+-------+
|                            |      |       |       |        |       |
+----------------------------+------+-------+-------+--------+-------+
|                            |      |       |       |        |       |
+----------------------------+------+-------+-------+--------+-------+
| **Page Totals:**           |      |       |       |        |       |
+----------------------------+------+-------+-------+--------+-------+
| # E                        |      |       | **[   | **[\   | **[   |
| xisting CCOP Physicians:\* |      |       | \_\_\ | _\_\_\ | \_\_\ |
|                            |      |       | _\_\_ | _\_\_\ | _\_\_ |
|                            |      |       | \_\_\ | _\_\_\ | \_\_\ |
|                            |      |       | _\_\_ | _\_]{. | _\_\_ |
|                            |      |       | ]{.un | underl | ]{.un |
|                            |      |       | derli | ine}** | derli |
|                            |      |       | ne}** |        | ne}** |
+----------------------------+------+-------+-------+--------+-------+
| > **All Physicians:**      |      |       | **[   | **[\   | **[   |
|                            |      |       | \_\_\ | _\_\_\ | \_\_\ |
|                            |      |       | _\_\_ | _\_\_\ | _\_\_ |
|                            |      |       | \_\_\ | _\_\_\ | \_\_\ |
|                            |      |       | _\_\_ | _\_]{. | _\_\_ |
|                            |      |       | ]{.un | underl | ]{.un |
|                            |      |       | derli | ine}** | derli |
|                            |      |       | ne}** |        | ne}** |
+----------------------------+------+-------+-------+--------+-------+
| **Grand totals (last page  |      |       |       |        |       |
| only):**                   |      |       |       |        |       |
+----------------------------+------+-------+-------+--------+-------+
| > **Existing CCOP          |      |       | **[   | **[\   | **[   |
| > Physicians**             |      |       | \_\_\ | _\_\_\ | \_\_\ |
|                            |      |       | _\_\_ | _\_\_\ | _\_\_ |
|                            |      |       | \_\_\ | _\_\_\ | \_\_\ |
|                            |      |       | _\_\_ | _\_]{. | _\_\_ |
|                            |      |       | ]{.un | underl | ]{.un |
|                            |      |       | derli | ine}** | derli |
|                            |      |       | ne}** |        | ne}** |
+----------------------------+------+-------+-------+--------+-------+
| > **All Physicians:**      |      |       | **[   | **[\   | **[   |
|                            |      |       | \_\_\ | _\_\_\ | \_\_\ |
|                            |      |       | _\_\_ | _\_\_\ | _\_\_ |
|                            |      |       | \_\_\ | _\_\_\ | \_\_\ |
|                            |      |       | _\_\_ | _\_]{. | _\_\_ |
|                            |      |       | ]{.un | underl | ]{.un |
|                            |      |       | derli | ine}** | derli |
|                            |      |       | ne}** |        | ne}** |
+----------------------------+------+-------+-------+--------+-------+
| **\* Applies to continuing |      |       |       |        |       |
| applicant only**           |      |       |       |        |       |
+----------------------------+------+-------+-------+--------+-------+
| **Narrative explanation    |      |       |       |        |       |
| may be attached if needed  |      |       |       |        |       |
| to fully document your     |      |       |       |        |       |
| experience.**              |      |       |       |        |       |
+----------------------------+------+-------+-------+--------+-------+

+------+--------------------------+-----------------------------------+---+
| *    |                          |                                   |   |
| *Acc |                          |                                   |   |
| rual |                          |                                   |   |
| to   |                          |                                   |   |
| ALL  |                          |                                   |   |
| O    |                          |                                   |   |
| THER |                          |                                   |   |
| Ca   |                          |                                   |   |
| ncer |                          |                                   |   |
| T    |                          |                                   |   |
| reat |                          |                                   |   |
| ment |                          |                                   |   |
| Clin |                          |                                   |   |
| ical |                          |                                   |   |
| Tr   |                          |                                   |   |
| ials |                          |                                   |   |
| Sa   |                          |                                   |   |
| mple |                          |                                   |   |
| T    |                          |                                   |   |
| able |                          |                                   |   |
| 6B** |                          |                                   |   |
+------+--------------------------+-----------------------------------+---+
|      |                          |                                   |   |
+------+--------------------------+-----------------------------------+---+
| **D  |                          |                                   |   |
| irec |                          |                                   |   |
| tion |                          |                                   |   |
| s:** |                          |                                   |   |
+------+--------------------------+-----------------------------------+---+
| **   | > **(2) Indicate if      |                                   |   |
| Colu | > currently              |                                   |   |
| mn** | > participating in CCOP  |                                   |   |
|      | > (Yes or No).**         |                                   |   |
|      | >                        |                                   |   |
|      | > **(3) Indicate trial   |                                   |   |
|      | > source: may be single  |                                   |   |
|      | > institution studies,   |                                   |   |
|      | > drug companies, local  |                                   |   |
|      | > hospitals, or          |                                   |   |
|      | > others.**              |                                   |   |
|      | >                        |                                   |   |
|      | > **(4) Code accrual by  |                                   |   |
|      | > predominant practice   |                                   |   |
|      | > mode for given year:** |                                   |   |
|      | >                        |                                   |   |
|      | > **private practice =   |                                   |   |
|      | > P; salaried academic = |                                   |   |
|      | > A; training/fellowship |                                   |   |
|      | > = F.**                 |                                   |   |
+------+--------------------------+-----------------------------------+---+

> **For all current and projected physicians, please list accrual by
> physician to all other trials**
>
> **(e.g.: pharmaceutical trials, etc.)**

+------------------+-----+-----------+----------+----------+----------+---+
| **(1)**          | *   | **(3)**   | **(4)**  |          |          |   |
|                  | *(2 |           |          |          |          |   |
| **Names of       | )** | **Trial** | **Number |          |          |   |
| Existing CCOP    |     |           | of       |          |          |   |
| Physicians\* and | **  | *         | Patients |          |          |   |
| Proposed**       | CCO | *Source** | E        |          |          |   |
|                  | P** |           | ntered** |          |          |   |
| **Participating  |     |           |          |          |          |   |
| Physicians**     | **P |           |          |          |          |   |
|                  | hys |           |          |          |          |   |
|                  | .** |           |          |          |          |   |
|                  |     |           |          |          |          |   |
|                  | **( |           |          |          |          |   |
|                  | Y/N |           |          |          |          |   |
|                  | )** |           |          |          |          |   |
+------------------+-----+-----------+----------+----------+----------+---+
|                  |     |           | **6/0    | **6/0    | **6/0    |   |
|                  |     |           | 5-5/06** | 6-5/07** | 7-5/08** |   |
+------------------+-----+-----------+----------+----------+----------+---+
| **Example: Jane  | **  | **Eli     | **0/F**  | **5/F**  | **10/A** |   |
| R. Doe, MD**     | Y** | Lilly**   |          |          |          |   |
+------------------+-----+-----------+----------+----------+----------+---+
|                  |     |           |          |          |          |   |
+------------------+-----+-----------+----------+----------+----------+---+
|                  |     |           |          |          |          |   |
+------------------+-----+-----------+----------+----------+----------+---+
|                  |     |           |          |          |          |   |
+------------------+-----+-----------+----------+----------+----------+---+
|                  |     |           |          |          |          |   |
+------------------+-----+-----------+----------+----------+----------+---+
|                  |     |           |          |          |          |   |
+------------------+-----+-----------+----------+----------+----------+---+
|                  |     |           |          |          |          |   |
+------------------+-----+-----------+----------+----------+----------+---+
|                  |     |           |          |          |          |   |
+------------------+-----+-----------+----------+----------+----------+---+
|                  |     |           |          |          |          |   |
+------------------+-----+-----------+----------+----------+----------+---+
|                  |     |           |          |          |          |   |
+------------------+-----+-----------+----------+----------+----------+---+
|                  |     |           |          |          |          |   |
+------------------+-----+-----------+----------+----------+----------+---+
|                  |     |           |          |          |          |   |
+------------------+-----+-----------+----------+----------+----------+---+
|                  |     |           |          |          |          |   |
+------------------+-----+-----------+----------+----------+----------+---+
|                  |     |           |          |          |          |   |
+------------------+-----+-----------+----------+----------+----------+---+
|                  |     |           |          |          |          |   |
+------------------+-----+-----------+----------+----------+----------+---+
|                  |     |           |          |          |          |   |
+------------------+-----+-----------+----------+----------+----------+---+
| **Page Totals:** |     |           |          |          |          |   |
+------------------+-----+-----------+----------+----------+----------+---+
| # Existing CC    |     |           | **[\     | **[\     | **[\     |   |
| OP Physicians:\* |     |           | _\_\_\_\ | _\_\_\_\ | _\_\_\_\ |   |
|                  |     |           | _\_\_\_\ | _\_\_\_\ | _\_\_\_\ |   |
|                  |     |           | _\_\_\_\ | _\_\_\_\ | _\_\_\_\ |   |
|                  |     |           | _]{.unde | _]{.unde | _]{.unde |   |
|                  |     |           | rline}** | rline}** | rline}** |   |
+------------------+-----+-----------+----------+----------+----------+---+
| > **All          |     |           | **[\     | **[\     | **[\     |   |
| > Physicians:**  |     |           | _\_\_\_\ | _\_\_\_\ | _\_\_\_\ |   |
|                  |     |           | _\_\_\_\ | _\_\_\_\ | _\_\_\_\ |   |
|                  |     |           | _\_\_\_\ | _\_\_\_\ | _\_\_\_\ |   |
|                  |     |           | _]{.unde | _]{.unde | _]{.unde |   |
|                  |     |           | rline}** | rline}** | rline}** |   |
+------------------+-----+-----------+----------+----------+----------+---+
| **Grand totals   |     |           |          |          |          |   |
| (last page       |     |           |          |          |          |   |
| only):**         |     |           |          |          |          |   |
+------------------+-----+-----------+----------+----------+----------+---+
| > **Existing     |     |           | **[\     | **[\     | **[\     |   |
| > CCOP           |     |           | _\_\_\_\ | _\_\_\_\ | _\_\_\_\ |   |
| > Physicians**   |     |           | _\_\_\_\ | _\_\_\_\ | _\_\_\_\ |   |
|                  |     |           | _\_\_\_\ | _\_\_\_\ | _\_\_\_\ |   |
|                  |     |           | _]{.unde | _]{.unde | _]{.unde |   |
|                  |     |           | rline}** | rline}** | rline}** |   |
+------------------+-----+-----------+----------+----------+----------+---+
| > **All          |     |           | **[\     | **[\     | **[\     |   |
| > Physicians:**  |     |           | _\_\_\_\ | _\_\_\_\ | _\_\_\_\ |   |
|                  |     |           | _\_\_\_\ | _\_\_\_\ | _\_\_\_\ |   |
|                  |     |           | _\_\_\_\ | _\_\_\_\ | _\_\_\_\ |   |
|                  |     |           | _]{.unde | _]{.unde | _]{.unde |   |
|                  |     |           | rline}** | rline}** | rline}** |   |
+------------------+-----+-----------+----------+----------+----------+---+
| **\***           |     |           |          |          |          |   |
|                  |     |           |          |          |          |   |
| **Applies to     |     |           |          |          |          |   |
| continuing       |     |           |          |          |          |   |
| applicant only** |     |           |          |          |          |   |
+------------------+-----+-----------+----------+----------+----------+---+
| **Narrative      |     |           |          |          |          |   |
| explanation may  |     |           |          |          |          |   |
| be attached if   |     |           |          |          |          |   |
| needed to fully  |     |           |          |          |          |   |
| document your    |     |           |          |          |          |   |
| experience.**    |     |           |          |          |          |   |
+------------------+-----+-----------+----------+----------+----------+---+

**Accrual to NCI APPROVED Cancer Prevention/Control Clinical Trials
Sample Table 6C**

**[Directions]{.underline}:**

**Column (2) Indicate if currently participating in CCOP (Yes or No).**

> **(3) Indicate trial source: name of cooperative group; cancer center;
> other organization**
>
> **(4) Code the accrual by predominant practice mode for a given
> year:**

**private practice = P; salaried academic = A; training/fellowship =
F.**

> **This table is intended to reflect current and proposed entries and
> is not a substitution for the total cancer prevention/control accrual
> in the progress report (if applicable). For all current and projected
> physicians, please list accrual by physician to all NCI approved
> trials (e.g.: Cooperative Group/Cancer Center Research Base
> protocols).**

+------------------+------+----------+---------+---------+-----------+
| **(1)**          | **(  | **(3)**  | **(4)** |         |           |
|                  | 2)** |          |         |         |           |
| **Names of       |      | *        | *       |         |           |
| Existing CCOP    | **CC | *Trial** | *Number |         |           |
| Physicians\* and | OP** |          | of      |         |           |
| Proposed**       |      | **       | Parti   |         |           |
|                  | *    | Source** | cipants |         |           |
| **Participating  | *Phy |          | En      |         |           |
| Physicians**     | s.** |          | tered** |         |           |
|                  |      |          |         |         |           |
|                  | *    |          |         |         |           |
|                  | *(Y/ |          |         |         |           |
|                  | N)** |          |         |         |           |
+------------------+------+----------+---------+---------+-----------+
|                  |      |          | **6/05  | **6/06  | **6/      |
|                  |      |          | -5/06** | -5/07** | 07-5/08** |
+------------------+------+----------+---------+---------+-----------+
| **Example: Jane  | *    | *        | **0/F** | *       | **20/A**  |
| R. Doe, MD**     | *Y** | *NSABP** |         | *13/F** |           |
+------------------+------+----------+---------+---------+-----------+
|                  |      |          |         |         |           |
+------------------+------+----------+---------+---------+-----------+
|                  |      |          |         |         |           |
+------------------+------+----------+---------+---------+-----------+
|                  |      |          |         |         |           |
+------------------+------+----------+---------+---------+-----------+
|                  |      |          |         |         |           |
+------------------+------+----------+---------+---------+-----------+
|                  |      |          |         |         |           |
+------------------+------+----------+---------+---------+-----------+
|                  |      |          |         |         |           |
+------------------+------+----------+---------+---------+-----------+
|                  |      |          |         |         |           |
+------------------+------+----------+---------+---------+-----------+
|                  |      |          |         |         |           |
+------------------+------+----------+---------+---------+-----------+
|                  |      |          |         |         |           |
+------------------+------+----------+---------+---------+-----------+
|                  |      |          |         |         |           |
+------------------+------+----------+---------+---------+-----------+
|                  |      |          |         |         |           |
+------------------+------+----------+---------+---------+-----------+
|                  |      |          |         |         |           |
+------------------+------+----------+---------+---------+-----------+
|                  |      |          |         |         |           |
+------------------+------+----------+---------+---------+-----------+
|                  |      |          |         |         |           |
+------------------+------+----------+---------+---------+-----------+
| **Page Totals:** |      |          |         |         |           |
+------------------+------+----------+---------+---------+-----------+
| # Existing CC    |      |          | **      | **      | **[       |
| OP Physicians:\* |      |          | [\_\_\_ | [\_\_\_ | \_\_\_\_\ |
|                  |      |          | \_\_\_\ | \_\_\_\ | _\_\_\_\_ |
|                  |      |          | _\_\_\_ | _\_\_\_ | \_\_\_\_\ |
|                  |      |          | \_\_\_] | \_\_\_] | _\_]{.und |
|                  |      |          | {.under | {.under | erline}** |
|                  |      |          | line}** | line}** |           |
+------------------+------+----------+---------+---------+-----------+
| > **All          |      |          | **      | **      | **[       |
| > Physicians:**  |      |          | [\_\_\_ | [\_\_\_ | \_\_\_\_\ |
|                  |      |          | \_\_\_\ | \_\_\_\ | _\_\_\_\_ |
|                  |      |          | _\_\_\_ | _\_\_\_ | \_\_\_\_\ |
|                  |      |          | \_\_\_] | \_\_\_] | _\_]{.und |
|                  |      |          | {.under | {.under | erline}** |
|                  |      |          | line}** | line}** |           |
+------------------+------+----------+---------+---------+-----------+
| **Grand totals   |      |          |         |         |           |
| (last page       |      |          |         |         |           |
| only):**         |      |          |         |         |           |
+------------------+------+----------+---------+---------+-----------+
| > **Existing     |      |          | **      | **      | **[       |
| > CCOP           |      |          | [\_\_\_ | [\_\_\_ | \_\_\_\_\ |
| > Physicians:**  |      |          | \_\_\_\ | \_\_\_\ | _\_\_\_\_ |
|                  |      |          | _\_\_\_ | _\_\_\_ | \_\_\_\_\ |
|                  |      |          | \_\_\_] | \_\_\_] | _\_]{.und |
|                  |      |          | {.under | {.under | erline}** |
|                  |      |          | line}** | line}** |           |
+------------------+------+----------+---------+---------+-----------+
| > **All          |      |          | **      | **      | **[       |
| > Physicians:**  |      |          | [\_\_\_ | [\_\_\_ | \_\_\_\_\ |
|                  |      |          | \_\_\_\ | \_\_\_\ | _\_\_\_\_ |
|                  |      |          | _\_\_\_ | _\_\_\_ | \_\_\_\_\ |
|                  |      |          | \_\_\_] | \_\_\_] | _\_]{.und |
|                  |      |          | {.under | {.under | erline}** |
|                  |      |          | line}** | line}** |           |
+------------------+------+----------+---------+---------+-----------+
| **\* Applies to  |      |          |         |         |           |
| continuing       |      |          |         |         |           |
| applicant only** |      |          |         |         |           |
+------------------+------+----------+---------+---------+-----------+
| **Narrative      |      |          |         |         |           |
| explanation may  |      |          |         |         |           |
| be attached if   |      |          |         |         |           |
| needed to fully  |      |          |         |         |           |
| document your    |      |          |         |         |           |
| experience.**    |      |          |         |         |           |
+------------------+------+----------+---------+---------+-----------+

**Accrual to NCI Approved Cancer Treatment Clinical Trials - ([Summary
for Progress Report]{.underline}) Sample Table 7A**

**Directions: Information to be provided as part of the Progress Report
(for prior funding period of up to 5 years) for applicants submitting
competing continuation applications.**

**Column (1) Indicate trial source: name of CCOP Research Base.**

**(2) Indicate the total number of patients and the credit equivalent
(see
<http://prevention.cancer.gov/programs-resources/programs/ccop/credit>)
entered onto NCI approved cancer treatment clinical trials.**

<table>
<colgroup>
<col style="width: 15%" />
<col style="width: 9%" />
<col style="width: 7%" />
<col style="width: 9%" />
<col style="width: 7%" />
<col style="width: 8%" />
<col style="width: 7%" />
<col style="width: 9%" />
<col style="width: 8%" />
<col style="width: 9%" />
<col style="width: 8%" />
</colgroup>
<tbody>
<tr class="odd">
<td rowspan="3"><p><strong>(1)</strong></p>
<p><strong>CCOP</strong></p>
<p><strong>Research Base</strong></p></td>
<td colspan="10"><p><strong>(2)</strong></p>
<p><strong>Number of Patients - Credits</strong></p></td>
</tr>
<tr class="even">
<td colspan="2"><strong>6/03 - 5/04</strong></td>
<td colspan="2"><strong>6/04 - 5/05</strong></td>
<td colspan="2"><strong>6/05 - 5/06</strong></td>
<td colspan="2"><strong>6/06 - 5/07</strong></td>
<td colspan="2"><strong>6/07 - 5/08</strong></td>
</tr>
<tr class="odd">
<td><strong>Patients</strong></td>
<td><strong>Credits</strong></td>
<td><strong>Patients</strong></td>
<td><strong>Credits</strong></td>
<td><strong>Patients</strong></td>
<td><strong>Credits</strong></td>
<td><strong>Patients</strong></td>
<td><strong>Credits</strong></td>
<td><strong>Patients</strong></td>
<td><strong>Credits</strong></td>
</tr>
<tr class="even">
<td><strong>Example: SWOG</strong></td>
<td><strong>63</strong></td>
<td><strong>63</strong></td>
<td><strong>75</strong></td>
<td><strong>75</strong></td>
<td><strong>60</strong></td>
<td><strong>55</strong></td>
<td><strong>80</strong></td>
<td><strong>80</strong></td>
<td><strong>75</strong></td>
<td><strong>70</strong></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>
<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><strong>Total Table 7A:</strong></td>
<td><strong><u>_________</u></strong></td>
<td><strong><u>_______</u></strong></td>
<td><strong><u>_________</u></strong></td>
<td><strong><u>_______</u></strong></td>
<td><strong><u>________</u></strong></td>
<td><strong><u>_______</u></strong></td>
<td><strong><u>_________</u></strong></td>
<td><strong><u>________</u></strong></td>
<td><strong><u>_________</u></strong></td>
<td><strong><u>________</u></strong></td>
</tr>
</tbody>
</table>

**Narrative explanation may be attached if needed to fully document your
experience.**

**Accrual to NCI Approved Cancer Prevention/Control Clinical Trials
[(Summary for Progress Report]{.underline}) Sample Table 7B**

**Directions: Information to be provided as part of the Progress Report
(for prior funding period of up to 5 years) for applicants submitting
competing continuation applications.**

**Column (1) Indicate trial source: name of CCOP Research Base.**

> **(2) Indicate the total number of new entry credits & follow-up (FU)
> credits (see
> <http://prevention.cancer.gov/programs-resources/programs/ccop/credit>)
> for accrual to NCI approved cancer prevention/control clinical
> trials.**

**[Special Instruction]{.underline}:**

**Please list the Study of Tamoxifen and Raloxifene (STAR) and the
Selenium and Vitamin E Trial in Prostate Cancer Prevention (SELECT) on
separate lines, if applicable.**

<table>
<colgroup>
<col style="width: 23%" />
<col style="width: 9%" />
<col style="width: 7%" />
<col style="width: 8%" />
<col style="width: 7%" />
<col style="width: 7%" />
<col style="width: 6%" />
<col style="width: 7%" />
<col style="width: 7%" />
<col style="width: 7%" />
<col style="width: 7%" />
</colgroup>
<tbody>
<tr class="odd">
<td rowspan="3"><p><strong>(1)</strong></p>
<p><strong>CCOP Research Base</strong></p></td>
<td colspan="10"><p><strong>(2)</strong></p>
<p><strong>New Entry Credits &amp; Follow-up Credits</strong></p></td>
</tr>
<tr class="even">
<td colspan="2"><strong>6/03 - 5/04</strong></td>
<td colspan="2"><strong>6/04 - 5/05</strong></td>
<td colspan="2"><strong>6/05 - 5/06</strong></td>
<td colspan="2"><strong>6/06 - 5/07</strong></td>
<td colspan="2"><strong>6/07 - 5/08</strong></td>
</tr>
<tr class="odd">
<td><p><strong>New</strong></p>
<p><strong>Entry</strong></p>
<p><strong>Credits</strong></p></td>
<td><p><strong>FU</strong></p>
<p><strong>Credits</strong></p></td>
<td><p><strong>New</strong></p>
<p><strong>Entry</strong></p>
<p><strong>Credits</strong></p></td>
<td><p><strong>FU</strong></p>
<p><strong>Credits</strong></p></td>
<td><p><strong>New</strong></p>
<p><strong>Entry Credits</strong></p></td>
<td><p><strong>FU</strong></p>
<p><strong>Credit</strong></p></td>
<td><p><strong>New</strong></p>
<p><strong>Entry</strong></p>
<p><strong>Credits</strong></p></td>
<td><p><strong>FU</strong></p>
<p><strong>Credits</strong></p></td>
<td><p><strong>New Entry</strong></p>
<p><strong>Credits</strong></p></td>
<td><p><strong>FU</strong></p>
<p><strong>Credits</strong></p></td>
</tr>
<tr class="even">
<td><strong>Example: SWOG</strong></td>
<td><strong>20</strong></td>
<td><strong>0</strong></td>
<td><strong>10</strong></td>
<td><strong>0</strong></td>
<td><strong>25</strong></td>
<td><strong>0</strong></td>
<td><strong>10</strong></td>
<td><strong>0</strong></td>
<td><strong>15</strong></td>
<td><strong>1</strong></td>
</tr>
<tr class="odd">
<td><strong>Example: STAR (NSABP P-2)</strong></td>
<td><strong>20</strong></td>
<td><strong>0</strong></td>
<td><strong>30</strong></td>
<td><strong>6</strong></td>
<td><strong>30</strong></td>
<td><strong>15</strong></td>
<td><strong>25</strong></td>
<td><strong>24</strong></td>
<td><strong>0</strong></td>
<td><strong>31.5</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><strong>Total Table 7B:</strong></td>
<td><strong>_________</strong></td>
<td><strong>________</strong></td>
<td><strong>_________</strong></td>
<td><strong>_______</strong></td>
<td><strong>_______</strong></td>
<td><strong>______</strong></td>
<td><strong>________</strong></td>
<td><strong>_______</strong></td>
<td><strong>________</strong></td>
<td><strong>_______</strong></td>
</tr>
<tr class="odd">
<td><strong>Total Credits/Year (New &amp; FU):</strong></td>
<td colspan="2"><strong>____________________</strong></td>
<td colspan="2"><strong>__________________</strong></td>
<td colspan="2"><strong>________________</strong></td>
<td colspan="2"><strong>__________________</strong></td>
<td colspan="2"><strong>__________________</strong></td>
</tr>
</tbody>
</table>

**Narrative explanation may be attached if needed to fully document your
experience.**

+--------+-------------------------------------------------------------+
| **Pr   |                                                             |
| oposed |                                                             |
| Re     |                                                             |
| search |                                                             |
| Base   |                                                             |
| Af     |                                                             |
| filiat |                                                             |
| ion(s) |                                                             |
| Sample |                                                             |
| Table  |                                                             |
| 8**    |                                                             |
+--------+-------------------------------------------------------------+
|        |                                                             |
+--------+-------------------------------------------------------------+
| ###    | > **See CCOP RFA, Section VI. 2. A. Cooperative Agreement   |
|  Direc | > Terms and Conditions of Award, 2.A.1. Part A.**           |
| tions: |                                                             |
|        | ###  CCOP Awardee Responsi                                  |
|        | bilities, Affiliations of CCOP Awardees with Research Bases |
+--------+-------------------------------------------------------------+

+-------------------------+------------------+--------+---------------+
| **Name of Research      | **Name &         | *      | **Cancer      |
| Base**                  | Location of      | *Treat | Prevention    |
|                         | Intermediary     | ment** | and**         |
|                         | Institution,**   |        |               |
|                         |                  | **Rese | **Control     |
|                         | **if             | arch** | Research**    |
|                         | Applicable**     |        |               |
|                         |                  | **Ye   | **Yes/No**    |
|                         |                  | s/No** |               |
+-------------------------+------------------+--------+---------------+
|                         |                  |        |               |
+-------------------------+------------------+--------+---------------+
|                         |                  |        |               |
+-------------------------+------------------+--------+---------------+
|                         |                  |        |               |
+-------------------------+------------------+--------+---------------+
|                         |                  |        |               |
+-------------------------+------------------+--------+---------------+
|                         |                  |        |               |
+-------------------------+------------------+--------+---------------+
|                         |                  |        |               |
+-------------------------+------------------+--------+---------------+

**In the narrative, describe previous working relationships with
proposed Research Base, if applicable.**

> **Include information on committee memberships and chairmanships as
> well as studies chaired.**

**If one or more components participated as cooperative group affiliate
program satellite hospitals, specify the years.**

Limit to two pages.

  -------------------- -------------------------------------------------------------
  **Projected Accrual  
  to NCI Approved      
  Cancer               
  Prevention/Control   
  Clinical Trials      
  during the Next Year 
  Sample Table 9**     

                       

  **Directions:**      **Organize by Research Base(s). Use separate page(s) for each
                       Research Base.**
  -------------------- -------------------------------------------------------------

**Name of Research Base:**

**This table should reflect the entire anticipated CCOP prevention and
control accrual for the coming year.**

+-------------------+---------+--------+---------+---+-----------+---+-------+
| **(1)**           | **(2)** | *      | **(4)** |   |           |   |       |
|                   |         | *(3)** |         |   |           |   |       |
| **Title**         | **NCI** |        | **Anti  |   |           |   |       |
|                   |         | **Dis  | cipated |   |           |   |       |
|                   | **Pro   | ease** | Parti   |   |           |   |       |
|                   | tocol** |        | cipants |   |           |   |       |
|                   |         | **     | Ac      |   |           |   |       |
|                   | **N     | Site** | crual** |   |           |   |       |
|                   | umber** |        |         |   |           |   |       |
+-------------------+---------+--------+---------+---+-----------+---+-------+
|                   |         |        | **Parti | * |           | * |       |
|                   |         |        | cipants | * |           | * |       |
|                   |         |        | Avai    | P |           | A |       |
|                   |         |        | lable** | a |           | c |       |
|                   |         |        |         | r |           | c |       |
|                   |         |        |         | t |           | r |       |
|                   |         |        |         | i |           | u |       |
|                   |         |        |         | c |           | a |       |
|                   |         |        |         | i |           | l |       |
|                   |         |        |         | p |           | * |       |
|                   |         |        |         | a |           | * |       |
|                   |         |        |         | n |           |   |       |
|                   |         |        |         | t |           | * |       |
|                   |         |        |         | s |           | * |       |
|                   |         |        |         | t |           | C |       |
|                   |         |        |         | o |           | r |       |
|                   |         |        |         | b |           | e |       |
|                   |         |        |         | e |           | d |       |
|                   |         |        |         | P |           | i |       |
|                   |         |        |         | l |           | t |       |
|                   |         |        |         | a |           | s |       |
|                   |         |        |         | c |           | ^ |       |
|                   |         |        |         | e |           | 1 |       |
|                   |         |        |         | d |           | ^ |       |
|                   |         |        |         | o |           | * |       |
|                   |         |        |         | n |           | * |       |
|                   |         |        |         | S |           |   |       |
|                   |         |        |         | t |           |   |       |
|                   |         |        |         | u |           |   |       |
|                   |         |        |         | d |           |   |       |
|                   |         |        |         | y |           |   |       |
|                   |         |        |         | * |           |   |       |
|                   |         |        |         | * |           |   |       |
+-------------------+---------+--------+---------+---+-----------+---+-------+
|                   |         |        |         |   |           |   |       |
+-------------------+---------+--------+---------+---+-----------+---+-------+
|                   |         |        |         |   |           |   |       |
+-------------------+---------+--------+---------+---+-----------+---+-------+
|                   |         |        |         |   |           |   |       |
+-------------------+---------+--------+---------+---+-----------+---+-------+
|                   |         |        |         |   |           |   |       |
+-------------------+---------+--------+---------+---+-----------+---+-------+
|                   |         |        |         |   |           |   |       |
+-------------------+---------+--------+---------+---+-----------+---+-------+
|                   |         |        |         |   |           |   |       |
+-------------------+---------+--------+---------+---+-----------+---+-------+
|                   |         | **Su   |         |   | **\_\_    |   | **\_\ |
|                   |         | btotal |         |   | \_\_\_\_\ |   | _\_\_ |
|                   |         | for    |         |   | _\_\_\_\_ |   | \_\_\ |
|                   |         | Re     |         |   | \_\_\_\_\ |   | _\_\_ |
|                   |         | search |         |   | _\_\_\_** |   | \_\_\ |
|                   |         | B      |         |   |           |   | _\_** |
|                   |         | ase:** |         |   |           |   |       |
+-------------------+---------+--------+---------+---+-----------+---+-------+
|                   |         | *      |         | * |           | * |       |
|                   |         | *Grand |         | * |           | * |       |
|                   |         | Total  |         | \ |           | \ |       |
|                   |         | (last  |         | _ |           | _ |       |
|                   |         | page   |         | \ |           | \ |       |
|                   |         | on     |         | _ |           | _ |       |
|                   |         | ly):** |         | \ |           | \ |       |
|                   |         |        |         | _ |           | _ |       |
|                   |         |        |         | \ |           | \ |       |
|                   |         |        |         | _ |           | _ |       |
|                   |         |        |         | \ |           | \ |       |
|                   |         |        |         | _ |           | _ |       |
|                   |         |        |         | \ |           | \ |       |
|                   |         |        |         | _ |           | _ |       |
|                   |         |        |         | \ |           | \ |       |
|                   |         |        |         | _ |           | _ |       |
|                   |         |        |         | \ |           | \ |       |
|                   |         |        |         | _ |           | _ |       |
|                   |         |        |         | \ |           | \ |       |
|                   |         |        |         | _ |           | _ |       |
|                   |         |        |         | \ |           | \ |       |
|                   |         |        |         | _ |           | _ |       |
|                   |         |        |         | \ |           | \ |       |
|                   |         |        |         | _ |           | _ |       |
|                   |         |        |         | \ |           | \ |       |
|                   |         |        |         | _ |           | _ |       |
|                   |         |        |         | \ |           | \ |       |
|                   |         |        |         | _ |           | _ |       |
|                   |         |        |         | \ |           | * |       |
|                   |         |        |         | _ |           | * |       |
|                   |         |        |         | \ |           |   |       |
|                   |         |        |         | _ |           |   |       |
|                   |         |        |         | \ |           |   |       |
|                   |         |        |         | _ |           |   |       |
|                   |         |        |         | \ |           |   |       |
|                   |         |        |         | _ |           |   |       |
|                   |         |        |         | \ |           |   |       |
|                   |         |        |         | _ |           |   |       |
|                   |         |        |         | \ |           |   |       |
|                   |         |        |         | _ |           |   |       |
|                   |         |        |         | * |           |   |       |
|                   |         |        |         | * |           |   |       |
+-------------------+---------+--------+---------+---+-----------+---+-------+

**^1^ For information on credit: see
<http://prevention.cancer.gov/programs-resources/programs/ccop/credit>**