INSTITUTIONAL REVIEW COMMITTEE

PROTOCOL SUBMISSION CHECKLIST

NAME OF STUDY SPONSOR GRANTING AGENCY:

TITLE OF PROJECT:

PRINCIPAL INVESTIGATOR (PI):

RESEARCH COORDINATOR/TELEPHONE/EMAIL:

MAILING ADDRESS:

PI EMAIL ADDRESS:

This form must be completed and submitted at the time of protocol submission to the IRC. Prior to review by the IRC, you will need to complete and email this form along with the required attachments to the IRC email, . Please refer to IRC Policy No. 2.1 “Guidelines for Protocol Submission”, (enclosed) for further information regarding your responsibilities as a Principal Investigator.

This section is to identify those health system resources that will be required as a result of this research project and are not part of standard patient care. Please check all that apply:

DepartmentNamePhone #Email Address

□ Laboratory Kem

□MicrobiologyDiane Halstead,

□ PharmacyNicole

□ Patient Financial SvcsMae

□ Cath LabFrank

□ Radiation Safety CommitteeNorman Brown

□ Surgical Ed Hubel

□ Emergency Department Denise Portera

□ Radiology/Nuclear MedicineBob Perez

□ HeartHospitalMichelle

□ Critical Care/Ortho/Neuro/

Dialysis/Venous Access/Blanca

□ Women’s Services/Med-Surg

Telemetry/Oncology/EndoMichelle

□ Quality AdministrationKristin Vondrak202-3247 kristin.vondrak@bmcjaxcom

Nursing:

□ Adult Nursing DivisionPeggy

□ Wolfson Nursing DivisionPam

□ Quality and EducationDoreen

□ Not Applicable

For those areas marked above, it is the responsibility of the Principal Investigator or Study Coordinator to contact each Director to discuss the impact this research project will have on their department. A copy of the protocol must be submitted to the designated person for each department to be involved in this study so that they can determine their departments’ ability to perform the part of the protocol that they will be involved with. By signing your name below, you are attesting that the appropriate communication has taken place.

If the research study is going to affect the standard billing practices, it is also the responsibility of the Principal Investigator or Study Coordinator, to contact the Director of Patient Financial Services, whenever a new patient is enrolled in this project. By signing your name below, you are acknowledging that you have fulfilled this responsibility.

Signature of Principal Investigator or Study CoordinatorDate

Printed Name