Ill. Admin. Code tit. 77, pt. 2085, exh. B
(Physician Letter Head)
Chief of Licensing
Illinois Department of Alcoholism and Substance Abuse
300 N. State Street-Suite 1500
Chicago, Illinois 60610
Sir:
I hereby apply for authorization from the Department to conduct research with Delta-9-Tetrahydrocannabinol under the National Cancer Institute (NCI) approved Protocol I 80-12 "Group C Guidelines for the Use of Delta-9-Tetrahydrocannabinol NSC 134454 for Nausea and Vomiting Induced by Antineoplastic Chemotherapy". Enclosed is a copy of FDA Form 1573 "Statement of Investigator" which has been submitted to NCI.
I agree to limit drug usage to the indications outlined in Group C Guidelines, to ensure that each patient has completed an informed consent form, to report adverse drug reactions immediately to the Department, as well as NCI, and to comply with Federal and State regulations concerning the use of THC. I will notify the Department if I no longer choose to participate in the research study.
Sincerely,
M.D.
___________________________________________________
Physician's Name
DEA # ________________
Illinois Controlled Substance # _________________________
Hospital Name and Address:
The above named physician has met the professional qualifications and possesses the requisite professional experience in Cancer Chemotherapy to participate in NCI Protocol I 80-12. This physician is approved to practice this therapy, under the NCI Protocol I 80-12, at __________ Hospital.
Director of Pharmacy ServicesHospital Administrator
Ill. Admin. Code tit. 77, pt. 2085, exh. B