VA Long Beach Healthcare System

VA Long Beach Healthcare System

IMPACT ESTIMATION WORKSHEET - PHARMACY SERVICE

As Principal Investigator (PI), I estimate that the prescriptions required during this investigation represent percent ROUTINE clinical care and percent RESEARCH. This worksheet is to assist in the development of your research project’s budget. Pharmacy service will provide the necessary support only for those projects, which have been, approve by the R&D Committee and the Chief, Pharmacy. The investigator must reimburse the MedicalCenter for the use of pharmacy resources.

Principal Investigator: Mail Code:

Study Title:

Research Study Number (MIRB):

Contact Phone: Contact Email:

Project Administrative Agency: SCIREVA Research and Development OfficeUCI

Account Number to be billed:

CALCULATIONS FOR EXPENSE (ESTIMATE ONLY):
I request waiver of Investigational Pharmacy fees . *Complete the estimation below even if you request a waiver.
Justification: ______
Chief, Pharmacy Service
Fees: / $20.00 per patient prescription
$50.00 per IV/chemo setup / Charge = (No. of subjects x No. of patient prescriptions x $20) + (number of subjects x No. of IV/chemo setups x $50)
No. of subjects / X / No. of outpatient prescriptions per subject / X / $20 / = / $
+
No. of subjects / X / No. of IV/chemo per subject / X / $50 / = / $
Subtotal / = / $
+
Study Administrative Fee* / = / $500
TOTAL ESTIMATED CHARGE** = Charge + Administrative Fee / = / $
* / Fee including the start-up, continuous monitoring, close-up and other administrative functions associated with the smooth progression of the study.
** / A prorated charge of $50.00 per hour will be accessed for any additional work required of the Investigational Pharmacist (IP), e.g., extraordinary preparatory time requirement, site monitoring, or meetings with regulatory representatives. A charge of minimally $100 (2 hours) will be billed for protocols call for patient randomization and initiation at off business hours (e.g. weekend and after 4:00 PM weekdays)
Any additional supplies, e.g., syringes, additional drugs, etc., required by the patient will be supplied by the Principal Investigator. Above Charges are estimates only. Final resolution of charges may exceed original estimate.
Principal Investigator / Date / Investigational Studies Pharmacist / Date
Chief, Pharmacy Service / Date

SCIRE Review for foundation projects ______

IEW-PharmacyInitials

Last Updated September 30, 2011. Supersedes Estimate Worksheet March 31, 2008