Alternate Contact Information. Address and contact information for a relative or other person through which PDPDCS may contact the scholar, if necessary.
Alternate Contact Information. Can patient be contacted directly?: □ Yes □ No If No, please provide information about the patient’s alternate contact (if consent to communicate with alternate contact has been obtained from patient): Name: Relationship:
Alternate Contact Information. Enter additional business or technical contact information. None of the fields are required. Enter business contact information. Contact Name: Contact Phone Number: (Enter numeric digits only, including area code. For example, enter 0000000000.) Contact Fax: (Enter numeric digits only, including area code. for example, enter 0000000000.) Contact E-mail: (Enter as: xxxx@xxxxxxxxx.xxx) Click if you want e-mail notifications sent to this e-mail address Enter technical support contact information. Contact Name: Contact Phone Number: (Enter numeric digits only, including area code. For example, enter 0000000000.) Contact Fax: (Enter numeric digits only, including area code. For example, enter 0000000000.) Contact E-mail: (Enter as: xxxx@xxxxxxxxx.xxx) ✔ Click if you want e-mail notifications sent to this e-mail address All files transferred using the FAST Levy batch application must be in text format. Files can be named using the standard FAST Levy file naming convention or the organization's file naming convention. Defaults have been chosen based on the selections being made by the majority of the organizations. Verify the defaults to make sure that the wrong selection is not made for your organization.
Alternate Contact Information. Address and contact information for a relative or other person through which DCC may contact the scholar, if necessary.
