Contacts Reference List

Study Stage: Set-up through Termination

Purpose: This template ensures that necessary staffand others can be contacted when needed. Use it to create a record of contact information for research team members and other partiesthat are involvedin the study.

Useful to:Principal Investigators, Study Coordinators, Monitors, MCRU (if applicable), Project Managers

Instructions:

  • Update the template below to include contact information for study team members and other key parties, for the study team’s reference
  • Add rows to the list to include contact information not already listed on the template that may be important for your study such as, coordinating sites, laboratories, clinic contacts, statisticians
  • Pages may be added to the template as needed

Best Practice Recommendations:

  • If a Sponsor provides a contact template, complete as instructed. Otherwise, gather a list of contact information from all parties involved in the specific study and storethe log in a place that is accessible to research team members. Note: maintaining the template electronically may facilitate ease of access.
  • Review the contacts listed periodicallyto ensure that it is uptodate

Template History

Last Updated: July 2015

Version: 2.0


Study Name: / IRB HUM #:
Principal Investigator:
Role and Name / Means of Contact / Contact Information
Investigator: / Phone:
Mobile:
Fax:
E-Mail:
Pager:
Administrative Assistant to Investigator: / Phone:
Mobile:
Fax:
E-Mail:
Pager:
Sub-investigator(s): / Phone:
Mobile:
Fax:
E-Mail:
Pager:
Sub-investigator(s): / Phone:
Mobile:
Fax:
E-Mail:
Pager:
Study Coordinator(s): / Phone:
Mobile:
Fax:
E-Mail:
Pager:
Study Coordinator(s): / Phone:
Mobile:
Fax:
E-Mail:
Pager:
Department Administrator/Manager: / Phone:
Mobile:
Fax:
E-Mail:
Data Manager/Statistician / Phone:
Mobile:
Fax:
E-Mail:
Pager:
MICHR (if applicable): / Phone:
Mobile:
Fax:
E-Mail:
Pager:
MCRU (if applicable): / Phone:
Mobile:
Fax:
E-Mail:
Pager:
MCRU (if applicable): / Phone:
Mobile:
Fax:
E-Mail:
Pager:
DRDA / Phone:
Mobile:
Fax:
E-Mail:
Accounts Payable (if applicable):
[Billing and Third Party Collections] / Phone:
Mobile:
Fax:
E-Mail:
Sponsor (if applicable): / Phone:
Mobile:
Fax:
E-Mail:
Sponsor (if applicable): / Phone:
Mobile:
Fax:
E-Mail:
CRO (if applicable): / Phone:
Mobile:
Fax:
E-Mail:
CRO (if applicable): / Phone:
Mobile:
Fax:
E-Mail:
NIH (if applicable):
[Project Officer] / Phone:
Mobile:
Fax:
E-Mail:
Pager:
Laboratory: / Phone:
Mobile:
Fax:
E-Mail:
Pager:
Laboratory: / Phone:
Mobile:
Fax:
E-Mail:
Pager:
Occupational Safety and Environmental Health (OSEH): / Phone:
Mobile:
Fax:
E-Mail:
Pager:
Occupational Safety and Environmental Health (OSEH): / Phone:
Mobile:
Fax:
E-Mail:
Pager:
Other (as needed): / Phone:
Mobile:
Fax:
E-Mail:
Pager:
Department Administrative Assistant: / Phone:
Mobile:
Fax:
E-Mail:
Pager:
Lead Pharmacist (if, applicable): / Phone:
Mobile:
Fax:
E-Mail:
Pager:
Pharmacist (if, applicable): / Phone:
Mobile:
Fax:
E-Mail:
Pager:
Pharmacist (if, applicable): / Phone:
Mobile:
Fax:
E-Mail:
Pager:
IRBMED: / Phone:
Mobile:
Fax:
E-Mail:
Pager:
IRBMED: / Phone:
Mobile:
Fax:
E-Mail:
Pager:
OHRCR (if applicable): / Phone:
Mobile:
Fax:
E-Mail:
Pager:

This template may be altered to meet study specific requirements; update as needed

Last Updated: MM/DD/YYYY

Version: Page _____