Transnational_Access_CA

Transnational Access Form – Clinical access

Fill in the following form to request beam time for clinical research

Through the following form you can submit your application for access to the clinical research TNA made available by HITRIplus partners. We remind you that, in case of clinical case submission, to evaluate your request, you shall satisfy following requirements:

You have the patient's consent to provide us his/her information for User Selection Panel eligibility assessment
You send us the documentation in English language, in original or properly translated by clinical experts
You are aware and inform the patient that his/her data will be used for the sole purpose of evaluating the case and your request to use our facilities and, if the case is not evaluated positively, they will be deleted within 3 months after you application.

For more information read our Privacy Policy Page .

Applicant's data

Period (approximately 5 working days)

Clinical facility preference CNAOHITMarburgMedAustron

Profession (number)

Report of the applicant physician (to be filled only for clinical case submission)

Patient information: disease diagnosis, disease stage, non-cancer history, detailed cancer history, ongoing therapies, drugs, active problems and any other information useful for the evaluation
Information on the reasons and objectives of the request to use the facility
File upload of (each in backward chronological order, clearly dated files):

physician’s letters, including tumor board (if available) and operation reports (if surgery was performed)
histology
imaging results (MRT, CT, PET-CT)
prior irradiation plans

Transnational Access Form – Clinical access

Fill in the following form to request beam time for clinical research

Applicant's data

Report of the applicant physician (to be filled only for clinical case submission)

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Transnational Access Form – Clinical access

Fill in the following form to request beam time for clinical research

Applicant's data

Report of the applicant physician (to be filled only for clinical case submission)

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