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 FORM

Note: 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)

# / ✔ / Description
A / 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

Classification
Predicted hours
Comments

INSTITUTIONAL VALIDATION

Approval
Comments

VI.BUDGET/BILLING DATA

INTERNAL
Institution:
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

1