Email: Phone: Medical (If Applicable): Medical Group (If Applicable): Name: Name: Email: Email: Phone: Phone: Medical (If Applicable): Medical Group (If Applicable): Name: Name: Email: Phone: Phone: Medical (If Applicable): Medical Group (If Applicable): Name: Name: Email: Email: Study Coordinator Phone: Phone: Medical Group (If Applicable): Medical Group (If Applicable): Name: Name: Other Research Email: Email: Staff Phone: Role: Role: Financial Relationships Are new financial relationships with any of the investigators not previously disclosed on the annual financial interest disclosures? Financial Yes (Explain): Relationships Attached updated Financial Disclosure Form No Site Resources and Assessment Department/Title: Department/Title: Name: Name: Department Email: Email: Representatives (For Phone: Phone: departments Department/Title: Department/Title: participating in or Name: Name: affected by the study, Email: Email: e.g.,Cardiac Cath Lab Phone: Phone: Manager for stent/ICD Department/Title: studies; Pharmacy, Name: Name: Radiology, etc.) Email: Email: Phone: Phone: Is non-hospital staff required to have direct observation for study procedures or have contact with hospital patients? **Yes, indicate type and frequency: Non-Hospital Staff No ** Non-hospital members will need to be registered with RepTrax or credentialed by Medical Staff Office as Allied Health Professionals (AHP) or its ministry specific equivalent. Pharmacy Services (Attach Sponsor’s Pharmacy Manual) Services Will a pharmacist’s time be required to maintain and dispense drugs? Yes** No **Pharmacist must review pharmacy manual and Investigator’s Brochure prior to submission.
Phone: Medical (If Applicable): Email: Medical Group (If Applicable): Name: Email: Phone: Medical (If Applicable): Name: Email: Phone: Medical Group (If Applicable): Name: Phone: Medical (If Applicable): Name: Email: Phone: Medical Group (If Applicable): Study Coordinator Name: Email: Phone: Medical Group (If Applicable): Name: Email: Phone: Medical Group (If Applicable): Other Research Staff Name: Email: Role: Name: Email: Phone: Role: Financial Relationships Financial Relationships Are new financial relationships with any of the investigators not previously disclosed on the annual financial interest disclosures? Yes (Explain): Attached updated Financial Disclosure Form No Site Resources and Assessment Department Representatives (For departments participating in or affected by the study, e.g.,Cardiac Cath Lab Manager for stent/ICD studies; Pharmacy, Radiology, etc.) Department/Title: Name: Email: Phone: Department/Title: Name: Email: Phone: Department/Title: Name: Email: Phone: Department/Title: Name: Email: Phone: Name: Email: Phone: Department/Title: Name: Email: Phone: Non-Hospital Staff Is non-hospital staff required to have direct observation for study procedures or have contact with hospital patients? **Yes, indicate type and frequency: No ** Non-hospital members will need to be registered with RepTrax or credentialed by Medical Staff Office as Allied Health Professionals (AHP) or its ministry specific equivalent. Services Pharmacy Services (Attach Sponsor’s Pharmacy Manual) Will a pharmacist’s time be required to maintain and dispense drugs? Yes** No **Pharmacist must review pharmacy manual and Investigator’s Brochure prior to submission.