Page 479 - eBook Version 8 Book 1 of 2 JUL 2022

To be completed by Research Administration:
PRE-TRIAL FEASIBILITY QUESTIONNAIRE
Materials Provided/ Work Needed
Department Sign Off
Protocol
IB
RX Management Other:
Pharmacy
☐ Yes ☐No ☐ N/A ☐Yes ☐No ☐N/A ☐ Yes ☐No ☐ N/A ☐ Yes ☐No ☐ N/A
Comments:
_____________________ Sign/Date
Laboratory and Pathology
Protocol Provided Lab Testing Local Lab Testing Central Shipping Needed Other:
☐ Yes ☐ Yes ☐ Yes ☐ Yes ☐ Yes
☐No ☐ N/A ☐No ☐ N/A ☐No ☐ N/A ☐No ☐ N/A ☐No ☐ N/A
Comments:
_____________________ Sign/Date
Protocol Provided X-rays
MRI
CT
US
Hard Copies Other:
Radiology
☐ Yes ☐No ☐ Yes ☐No ☐ Yes ☐No
☐Yes ☐No ☐Yes ☐No ☐ Yes ☐No ☐ Yes ☐No
☐ N/A ☐ N/A ☐ N/A
☐N/A ☐N/A ☐ N/A ☐ N/A
Comments:
_____________________ Sign/Date
Protocol Provided IB
RX Management Other:
Cardiology
☐ Yes ☐No ☐ N/A ☐Yes ☐No ☐N/A ☐ Yes ☐No ☐ N/A ☐ Yes ☐No ☐ N/A
Comments:
_____________________ Sign/Date
Nursing
Protocol Provided ☐ Yes ☐No Staff Education Needed ☐ Yes ☐No Other: ☐ Yes ☐No
☐ N/A ☐ N/A ☐ N/A
Comments:
_____________________ Sign/Date
Finance Department
Protocol Provided Contract/Budget Other:
☐ Yes ☐ Yes ☐ Yes
☐No ☐ N/A ☐No ☐ N/A ☐No ☐ N/A
Comments:
_____________________ Sign/Date
Department Head
Protocol Provided ☐ Yes ☐No ☐ N/A Other: ☐ Yes ☐No ☐ N/A
Comments:
_____________________ Sign/Date
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