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 *Select your Country... Afghanistan Åland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Congo, The Democratic Republic of The Cook Islands Costa Rica Cote D'ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-bissau Guyana Haiti Heard Island and Mcdonald Islands Holy See (Vatican City State) Honduras Hong Kong Hungary Iceland India Indonesia Iran, Islamic Republic of Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Korea, Democratic People's Republic of Korea, Republic of Kuwait Kyrgyzstan Lao People's Democratic Republic Latvia Lebanon Lesotho Liberia Libyan Arab Jamahiriya Liechtenstein Lithuania Luxembourg Macao Macedonia, The Former Yugoslav Republic of Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia, Federated States of Moldova, Republic of Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Palestinian Territory, Occupied Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russian Federation Rwanda Saint Helena Saint Kitts and Nevis Saint Lucia Saint Pierre and Miquelon Saint Vincent and The Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and The South Sandwich Islands Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syrian Arab Republic Taiwan Tajikistan Tanzania, United Republic of Thailand Timor-leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Venezuela Viet Nam Virgin Islands, British Virgin Islands, U.S. Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Period (approximately 5 working days) Clinical facility preference CNAOHITMarburgMedAustron *Number of users... 1 2 3 Profession (number) *Radiotherapists... 0 1 2 3 *Medical oncologists... 0 1 2 3 *Surgeon... 0 1 2 3 *Medical Physicists... 0 1 2 3 *Technician... 0 1 2 3 *Clinical research topic... Clinical case submission for Carbon ion treatment Treatment plans comparison (photons, C-ions, protons) Clinical cases discussion for C-ion eligibility Clinical trial research in Hadrontherapy Other clinical research on Hadrontherapy 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 Send