Place a in the columns that apply. “√” List all that are Standard of Paid for by Charge Patient- Charge Investigator # Per Subject applicable; ie, Chart Care study budget (Must be disclosed in the Research Account Review, Procedure, informed consent) Test, Survey, Medication, Device, Supply or Service My name typed below shall have the same force and effect and is as legally binding as my written signature. ___________________________________________ ________________ Principal Investigator Signature Date ___________________________________________ ________________ Person Completing Form, Name, Credentials, Title Date ************************************************************************************* Parkview Health Administrative Approval: Approved Rejected If Rejected Date Investigator Contacted – ___________________________________________________ _________________ Parkview Administrative Reviewer Signature, Credentials, Date
Place a “√” in the columns that apply. List all that are applicable; ie, Chart Review, Procedure, Test, Survey, Medication, Device, Supply or Service Standard of Care Paid for by study budget Charge Patient- (Must be disclosed in the informed consent) Charge Investigator Research Account # Per Subject My name typed below shall have the same force and effect and is as legally binding as my written signature. ___________________________________________ ________________ Principal Investigator Signature Date ___________________________________________ ________________ Person Completing Form, Name, Credentials, Title Date ************************************************************************************* Parkview Health Administrative Approval: Approved Rejected If Rejected – Date Investigator Contacted ___________________________________________________ _________________ Parkview Administrative Reviewer Signature, Credentials, Date
Parkview%20Health%20Clinical%20Research%20Proposal%20Form%20(PHCRPF).docx