Evaluation of STVHCS Resources for Clinical Research 1. Principal Investigator/Program Director: Last First MI Degree 2. Project Title: (Maximum length = 142 characters, including spaces) 3. Funded by: Administered By: VA Biomedical Research Foundation of UTHSCSA one) Other _ __________________________________ 4. UTHSCSA IRB Number: 5. Initial Evaluation Form Modified Evaluation Form (only select one) 6. Starting Date of Support (mm/dd/yy) Ending Date of Support: (mm/dd/yy) 7. Number of Subjects: Total enrolled at Veterans enrolled at STVHCS: Non-Veterans enrolled at STVHCS: STVHCS: Inpatients: Inpatients: Outpatients: Outpatients: 8. BARTTER RESEARCH UNIT (BRU) Being Used: Yes No (Check one) 9. Procedures Beyond Routine Clinical Care (Additional, Altered Process or Increased Frequency) F. Imaging Service Number Number of of Procedures Patients Per Patient Procedure Specify visit(s) that Other Information DESCRIBE procedure(s) will be (CPT Code Required) conducted For Radiology use only: Radiology Service CAN CANNOT provide the resources necessary to effectively and safely conduct the research. Any limitations are attached. Chief, Imaging Service Signature Date
Evaluation of STVHCS Resources for Clinical Research 1. Principal Investigator/Program Director: Last First MI Degree 2. Project Title: (Maximum length = 142 characters, including spaces) 3. Funded by: Administered By: VA Biomedical Research Foundation of UTHSCSA one) Other _ __________________________________ 4. UTHSCSA IRB Number: 5. Initial Evaluation Form Modified Evaluation Form (only select one) 6. Starting Date of Support (mm/dd/yy) Ending Date of Support: (mm/dd/yy) 7. Number of Subjects: Total enrolled at STVHCS: Veterans enrolled at STVHCS: Non-Veterans enrolled at STVHCS: Inpatients: Inpatients: Outpatients: Outpatients: 8. BARTTER RESEARCH UNIT (BRU) Being Used: Yes No (Check one) 9. Procedures Beyond Routine Clinical Care (Additional, Altered Process or Increased Frequency) F. Imaging Service Number of Patients Number of Procedures Per Patient Procedure DESCRIBE Specify visit(s) that procedure(s) will be conducted Other Information (CPT Code Required) For Radiology use only: Radiology Service CAN CANNOT provide the resources necessary to effectively and safely conduct the research. Any limitations are attached. Chief, Imaging Service Signature Date
ImagingServiceEvaluationSTVHCSResourcesClinicalResearch.docx