NYGH REB #

Departmental Approval for Application to the Research Ethics Board

STUDY PROTOCOL TITLE:

PRINCIPAL INVESTIGATOR
PRINT / SIGNATURE / TITLE / DATE / N/A
NYGH SITE INVESTIGATOR
PRINT / SIGNATURE / TITLE / DATE / N/A
CANCER CARE PROGRAM
PRINT
Lorraine Carrington / SIGNATURE / TITLE
Director, Cancer Care Program / DATE / N/A
PRINT
Dr. Daryl Roitman / SIGNATURE / TITLE
Medical Director, Cancer Care / DATE / N/A
CRITICAL CARE (ICU)
PRINT
Dr. Donna McRitchie / SIGNATURE / TITLE
Chief and Medical Director / DATE / N/A
PRINT
Lorraine Carrington / SIGNATURE / TITLE
Director, Medical Program / DATE / N/A
DIAGNOSTIC IMAGING
PRINT
Dr. Elizabeth Lamere (756-6289) / SIGNATURE / TITLE
Chief Radiologist and Medical Director / DATE / N/A
PRINT
Gregory Konigshaus / SIGNATURE / TITLE
Director, Medical Imaging, Cardio & Neurological Diagnostics / DATE / N/A
ELDER CARE
PRINT
Suzanne MacKenzie / SIGNATURE / TITLE
Director, Elder Care / DATE / N/A
EMERGENCY SERVICES
PRINT
Dr. Kuldeep Sidhu (756-6166) / SIGNATURE / TITLE
Chief & Medical Director / DATE / N/A
PRINT
Ms. Susan Woollard (756-6679) / SIGNATURE / TITLE
Director, Emergency Services / DATE / N/A
FAMILY AND COMMUNITY MEDICINE
PRINT
Dr. David White (756-6019) / SIGNATURE / TITLE
Chief & Medical Director / DATE / N/A
PRINT
Dr. PERLE FELDMAN (756-6019)
/
SIGNATURE
/ TITLE
Program Director, Postgraduate
/ DATE
GENETICS
PRINT
Dr. wendy Meschino (756-6076) / SIGNATURE / TITLE
Deputy Chief & Medical Director / DATE / N/A
PRINT
Gregory Konigshaus / SIGNATURE / TITLE
DIRECTOR,LABORATORY MEDCNE / DATE / N/A
HEALTH RECORDS
PRINT
Maria Muia / SIGNATURE / TITLE
Director / DATE / N/A
INFORMATION SERVICES
PRINT
Sandy Saggar
(756-6790) / SIGNATURE / TITLE
Director / DATE / N/A
PRINT / SIGNATURE / TITLE:
Director Clinical Informatics / DATE / N?A
INFECTION PREVENTION AND CONTROL
PRINT
Dr. Kevin Katz
/
SIGNATURE
/ TITLE
Medical Director
/ DATE / N/A
TOTAL JOINT ASSESSMENT CENTRE
PRINT
Bibi Rampersad / SIGNATURE / TITLE
Clinical Team Manager / DATE / N/A
LABORATORY
PRINT
Dr. Denis MacDonald (756-6517) / SIGNATURE / TITLE
Director of Laboratories & Chief of Pathology / DATE / N/A
PRINT
Gregory Konigshaus / SIGNATURE / TITLE
DIRECTOR,LABORATORY MEDCNE / DATE / N/A
MEDICAL PROGRAM
PRINT
Dr. David Baron (756-6410) / SIGNATURE / TITLE
Chief & Medical Director / date / N/A
PRINT
Ms. Lorraine Carrington / SIGNATURE / TITLE
Director, Medical Program / DATE / N/A
OBSTETRICS AND GYNECOLOGY
PRINT
Dr. TITUS OWOLABI(756-6114) / SIGNATURE / TITLE
Chief, Obstetrics & Gynaecology / date / N/A
PRINT
Cathie Badeau / SIGNATURE / TITLE
Director, Maternal Newborn / date / N/A
PAEDIATRICS
PRINT
Dr. Glenn Berall / SIGNATURE / TITLE
Chief & Medical Director / DATE / N/A
Ms. Cathie Badeau / SIGNATURE / TITLE
Director, Maternal Newborn / DATE / N/A
PHARMACY SERVICES
PRINT
Doris nessim (756-6099) / SIGNATURE / TITLE
Director / DATE / N/A
PROFESSIONAL PRACTICE
PRINT
Susan Woollard / SIGNATURE / TITLE
Director, Professional Practice Research and Education / DATE / N/A
MENTAL HEALTH
PRINT
Dr. Tom Ungar (756-6861) / SIGNATURE / TITLE
Chief & Medical Director / DATE / N/A
PRINT
Saul Goodman / SIGNATURE / TITLE
Director / DATE / N/A
SURGICAL PROGRAM
PRINT
Dr. Stan Feinberg (756-6764) / SIGNATURE / TITLE
Chief & Medical Director / DATE / N/A
PRINT
Linda Jussaume / SIGNATURE / TITLE
Director, Surgical Program / DATE / N/A

Please review and indicate your support by signing this signature sheet and/or comment to us on a separate sheet. It is REB criteria that all research studies receive support from the heads of departments impacted by the study prior to the meeting. Your assistance in meeting this criterion is much appreciated.

NorthYorkGeneralHospital Research Ethics Board Office,

4001 Leslie Street, 6 North Room 630

TorontoONM2K 1E1

416-756-6828 or Fax 416-756-6916

Please MAIL/FAX (416-756-6916) with any additional sheets to the REB Office by:

Revised July 23, 2010