STUDY INFORMATION: Institutional Review (IRB)# Full of Study: PI Contact Information Last Name, First Name/Degrees: Office #: Cell/pager #: E-Mail Address: PI has privileges to perform the yes no study PI Department/Division/Specialty List Co-PI and Sub investigators Last Name, First Name/Degrees: Study Coordinator Contact Last Name, First Name: Information Office #: #: E-Mail Address: Finance Contact (ex. ORA Last Name, First Name: analyst) Office #: E-Mail Address: STUDY DETAILS Drug Device Diagnostic Biologic Chart review Epidemiologic Study Type/Study Design Retrospective chart review (select all that apply) Observational Registry Creating database Therapeutic Prospective Blind Double blind Placebo controlled other: Stratification Randomized Not randomized Phase of the Study 0 1 2 3 4
STUDY INFORMATION: Institutional Review (IRB)# Full of Study: PI Contact Information Last Name, First Name/Degrees: Office #: Cell/pager #: E-Mail Address: PI has privileges to perform the study yes no PI Department/Division/Specialty List Co-PI and Sub investigators Last Name, First Name/Degrees: Study Coordinator Contact Information Last Name, First Name: Office #: #: E-Mail Address: Finance Contact (ex. ORA analyst) Last Name, First Name: Office #: E-Mail Address: STUDY DETAILS Study Type/Study Design (select all that apply) Drug Device Diagnostic Biologic Chart review Epidemiologic Retrospective chart review Observational Registry Creating database Therapeutic Prospective Blind Double blind Placebo controlled other: Stratification Randomized Not randomized Phase of the Study 0 1 2 3 4
UHT_Research_Services_Resources_Requested_Form.docx