NOTE: This Resource Utilization Template is only a reference model and will be adapted in different ways by each of the three hospitals. Contact the person responsible for administrative approval to clarify the approval process in a particular hospital. THREB itself requires only the signed Administrative Approval page and the budget. Requirements: It is the responsibility of the applicant to ensure that all from which resources will be required have been consulted and have indicated agreement by signing this form. Approval of the project is conditional upon satisfactory completion of this section. A separate resources form must be filled in for each institution in which the research will be conducted. If a required area has not been consulted and approval received, the application may be returned for completion. Institutional Services, Staff or Equipment: If your participant will be admitted to hospital and/or will require any hospital services, as a requirement of this study, which are over and above standard treatment, you obtain appropriate signatures. must If the study involves more than one unit or service in the hospital, signatures must be obtained from all areas involved. In all cases, budgets should cover institutional costs and overhead if required, unless otherwise agreed upon by the appropriate Administrator. Health Records/Health Information/Decision Support Services: 1. Will you require Health Records/Information to pull charts for you? YES NO 2. Will you require Decision Support Services to identify your research population? YES NO 3. Do you require patient specific data from Decision Support to support your project? YES NO 4. Do you require summary cost data to support your project? YES NO 5. If YES to any of 1 to 4 above, have you allowed for these services in the budget? YES NO CHECK AREAS BELOW WHERE RESOURCES ARE REQUIRED () Area Authorized Official Signature Health Information/Records Decision Support Laboratory Services Medication/Drugs(Pharmacy) Radiology/Diagnostic/Medical Imaging Resources Nuclear Medicine Radiation Safety (please Other specify) Approvals are required from individuals responsible for nursing and clinical care of each patient area to be utilized Hospital Area Authorized Official Signature (E.g. Inpatient/Outpatient Location) (Manager/Director)
NOTE: This Resource Utilization Template is only a reference model and will be adapted in different ways by each of the three hospitals. Contact the person responsible for administrative approval to clarify the approval process in a particular hospital. THREB itself requires only the signed Administrative Approval page and the budget. Requirements: It is the responsibility of the applicant to ensure that all from which resources will be required have been consulted and have indicated agreement by signing this form. Approval of the project is conditional upon satisfactory completion of this section. A separate resources form must be filled in for each institution in which the research will be conducted. If a required area has not been consulted and approval received, the application may be returned for completion. Institutional Services, Staff or Equipment: If your participant will be admitted to hospital and/or will require any hospital services, as a requirement of this study, which are over and above standard treatment, you must obtain appropriate signatures. If the study involves more than one unit or service in the hospital, signatures must be obtained from all areas involved. In all cases, budgets should cover institutional costs and overhead if required, unless otherwise agreed upon by the appropriate Administrator. Health Records/Health Information/Decision Support Services: 1. Will you require Health Records/Information to pull charts for you? YES NO 2. Will you require Decision Support Services to identify your research population? YES NO 3. Do you require patient specific data from Decision Support to support your project? YES NO 4. Do you require summary cost data to support your project? YES NO 5. If YES to any of 1 to 4 above, have you allowed for these services in the budget? YES NO CHECK AREAS BELOW WHERE RESOURCES ARE REQUIRED () Area Authorized Official Signature Health Information/Records Decision Support Laboratory Services Medication/Drugs(Pharmacy) Radiology/Diagnostic/Medical Imaging Resources Nuclear Medicine Radiation Safety Other (please specify) Approvals are required from individuals responsible for nursing and clinical care of each patient area to be utilized Hospital Area (E.g. Inpatient/Outpatient Location) Authorized Official (Manager/Director) Signature
Part-3-Administrative-Approval-vOct2017.docx