Page 510 - eBook Version 8 Book 1 of 2 JUL 2022
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Research Monitor request form
2022
Instructions:
This form must be filled out by a Children’s employee or credentialed UT Southwestern Researcher. Forward the completed form to Deborah Town for approval. Once approved, the approver will send the form along with her electronic signature to AccessManagement@Childrens.com to be processed. Please allow 10 business days for processing.
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Contact Information
Requestor’s information
Name Phone# Email Department
Approving Supervisor
Name Phone# Email Department
Deborah Town
214-456-2253
deborah.town@chil
Professional Service
Monitor’s Information
Name Phone#
Email Employer Title
Reporting department Requested Start Date Enter
today’s date
Expiration Date (Not to exceed one year) Enter date to be exactly one year from Requested Start Date
Will user be on site for more than 5 days? This will always be “No” and
means access can not be given more than 5 consecutive days in a row.
Research Administration
No Yes
Please provide three of the below identifiers.
Monitor to complete this section.
Four-digit PIN:
Last four of Social security:
Date of birth:
Mother’s maiden name:
Make of first car:
Name of best friend:
Name of high school mascot:
