Letter of Support Request Form

Pediatric PittNet

Letter of Support Request Form

A Letter of Support Request Form should be submitted to Pediatric PittNet so that the letter can be included in grant applications to the funding agency. An Application for Services must be submitted toPediatric PittNet upon initial IRB submission or once IRB approval has been granted. Research activity cannot begin inPediatric PittNet sites without IRB and Executive Committee approval.

In addition to Pediatric PittNet, do you plan to use any other CTRC(s)/PCIR Cores?

Yes ☐No☐

Check all that apply:

☐UPCI CTRC

☐ Vascular CTRC

☐ Neuroscience CTRC (WPIC)

☐ Magee-Womens CTRC

☐ Pediatric CTRC (Childrens)

☐ Physical Therapy CTRC

CONTACT INFORMATION

Principal Investigator:

Degree:If more than one degree, choose primary

Choose an item.

Other:

School-Department: Choose an item.

Other:

Division: Choose an item.

Other:

Academic Appt: Choose an item.

Other:

Phone: Email:

Mailing Address:

City: State: Zip:

Do you have an Administrative Assistant?Yes ☐No☐

Administrative Assistant Name:

Administrative Assistant Email:

Do you have a Regulatory Coordinator?Yes ☐No☐

Regulatory Coordinator Name:

Regulatory Coordinator Email:

Do you have a Research Coordinator?Yes ☐No☐

Research Coordinator Name:

Research Coordinator Email:

PROTOCOL INFORMATION

Protocol Title:

Pending Protocol Funding Source:

Choose an item.

Other:

Is the University of Pittsburgh the Institute of the Funded Grant?

Yes ☐No☐

If no, Institute of the Funded Grant:

Clinical Trial

Enrollment of human subjects; biomedical/behavioral research study of human subjects designed to answer specific questions about interventions.

Yes ☐No☐

IND/IDE

Use of Investigational new drug/Investigation Device Exemption

Yes ☐No☐

Recruitment Assistance Levels

All studies requesting on-site recruitment must schedule a meeting with the Pediatric PittNet Administrator to discuss a budget to support services provided by Pediatric PittNet Research Nurses.

Please contact:

Carrie Fascetti

412 246 5283

Level of Activity:

☐On-site

☐Posting

☐Other

Identification:Yes ☐No☐

Pediatric PittNet Research Nurses identify and screen eligible patients via schedule and chart review, screening child/family, etc.

Enrollment:Yes ☐No☐

Pediatric PittNet Research Nurses enroll and consent research subjects (i.e. nurse is trained by PI to obtain consent and implement protocol in pediatrics practices).

Please explain specific recruitment expectations of Pediatric PittNet:

Total length of study enrollment Period:Choose an item.

Number of subjects:

Number of visits per subject:

Duration of study per subject:Choose an item.

STUDY SUMMARIES

Summary of specific aims and methods:Use this section to outline the primary and secondary aims as well as research study methods.

Importance of the Study:Use this section to convince the Pediatric PittNet review committee why this research is important and why it is important for pediatrics. Include benefits of the research.

Protocol Summary: Study Abstract