Diagnostic Cardiology Unit - Research Costing & Approval Form

·  Send completed form and all research correspondence to and

·  Please copy in STH Cardiology Directorate Research Coordinator

·  Please attach an electronic copy of the Research Protocol and/or study specific procedure document*

·  Please provide information on any specific test reporting – specifically any Echo measurements additional to the standard Echo protocol.

Questions / Response
Full title of study and protocol version number.
STH Project Registration Number.
Name of Principal Investigator and Primary Contact.
Study Dates. / Estimated Start Date: / Recruitment End Date: / Study End Date:
Site where tests to be performed e.g. RHH, NGH, WPH.

TESTING REQUIREMENTS

Examination/ Test Type / Total Number of patients / Maximum number of tests per patient / How many of these are standard of care per patient? / Please list each visit window for arrangement of appointments / Frequency of procedures to be performed e.g. Baseline, 6, 12, 18 months. / Primary Purpose of the Test (Treatment / Diagnostic, Safety, Data for study) / DCU staff responsible for reporting / Transfer to CD
(£10 per image)
Echocardiogram
ECG
ETT
24 Hour Holter Monitor

*Without a protocol or study specific procedure protocol it may not be possible to provide a costing and confirmation of DCU support.

Diagnostic Cardiology Unit Research Approval Form, Version 2.2 July 2017

DCU Acceptance Conditions

Best efforts will be made in order to expedite these tests within a timely manner. However please be aware at times waiting lists may be lengthy. We cannot guarantee that Echos will be done at short notice.

When requesting a test, please include the STH Project Research Number, and state the latest date/window that test can be performed.

If DCU are not informed that the requested test is part of a research study, the test performed will be a standard test. Any additional measurement required for that study will not be undertaken.

It is not always possible to obtain all standard measurements (including an Ejection Fraction) during an Echo. Best efforts will always be made to obtain all information.

Diagnostic Cardiology Unit Research Approval Form, Version 2.1 PE July 2017