Medical Statistics core facility
Plataforma d’Estadística Mèdica
183, Mallorca Street. Floor -1. Office #60. 08036 Barcelona
http://www.idibaps.org/core-facilities/11/medical-statistics
APPOINTMENT/VALIDATION FORMNote: An appointment must be made for a face-to-face meeting. No queries will be answered by phone or email.
Identification: / (CAMP AUTOMATIC ANY-COMPTADOR COM A ID, Ex.: 2015-001)Hour/day / (CAMP AUTOMATIC DATA i HORA)
I. INVESTIGATOR DATA (PI)
Name:Surname:
Organization: / Foundation / IDIBAPS / Hospital
Others:
Service/Dept./Unit:
Institution:
Location:
II. CONTACT DATA(include at least a phone number and an e-mail for contact purposes)
Name: / (needed if different from PI)Surname: / (needed if different from PI)
Address:
Phone/s:
Cell phone/s:
Pager:
E-mail:
Other:
III. USERS
Usuaris autoritzats:Users e-mail/s:
IV. CONSULTATION/ASSESSMENT
Title:Acronym:
Code:
Key words: / (words to facilitate searches)
Subject: / (short summary of the reasons for consultation/assessment)
Starting date and end of project: / (short summary of the reasons for consultation/assessment)
V. FUNCTIONAL CLASSIFICATION OF THE PROJECT
ASSESSMENT BY YOU (tick one)
# / ✔ / DescriptionA / Project funded and self-sufficient
B* / Projects to assess potential IDIBAPS funding
B.I / Initial assessment, planning and/or budget of a project
B.II / Review of project for presentation in competitive call (FIS, H2020, etc.) with budgetary compensation for the platform included in the memory
Specify: / FIS / H2020 / ISCIII / Others:
B.III / Short-term assessment or analysis that cannot be funded in other ways
B.IV / Other underfunded projects with high scientific impact
B.V / Other projects not included in the previous sections
* Explanatory notes:
· Services will be provided without further validation by IDIBAPS only for categories BI and B.II.
· For categories B.III, B.IV, and B.V, the following should be taken into account:
o We may provide a service that does not cover 100% of the costs according to the rates and/or budget generated by the platform only in some exceptional cases, and always with prior authorization and IDIBAPS validation,
o All projects must be validated by the Medical Statistics platform; an indicative budget will be provided that will serve, together with the justification of the user, as elements for IDIBAPS validation.
· In all these cases a statement of the costs to be borne by IDIBAPS will be issued for user information, and therefore section V (data for budget and/or billing) must be completed.
ONLY FOR CATEGORIES B.III, B.IVAND B.V
REASONED JUSTIFICATION FROM USER
EVALUATION BY MEDICAL STATISTICS
ClassificationPredicted hours
Comments
INSTITUTIONAL VALIDATION
ApprovalComments
VI.BUDGET/BILLING DATA
INTERNALInstitution:
SAP CODE:
EXTERNAL
Institution:
Address:
NIF/CIF:
COMMENTS:
Medical Statistics core facility
IDIBAPS - Hospital Clinic Barcelona
183, Mallorca Street. Floor -1. Office #60. 08036 Barcelona
http://www.idibaps.org/core-facilities/11/medical-statistics
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