Page 525 - eBook Version 8 Book 1 of 2 JUL 2022

Research Monitor request form
2022
Please select the type of relationship for this user
Consultant
Vendor Volunteer
Is the person for whom access is being requested in the process of or subject to being credentialed/screened by any of the following Children’s Departments:
• Human Resources (fulltime/part time children’s employees and contractors)
• Graduate Medical Education (fellows, residents, and medical students)
• Medical Staff Services (physicians, advanced practice nurses, allied health professionals)
• Clinical Education (nursing students)
If so, then stop, do not complete this form. Please contact the Children’s Department that processes that category of staff.
No Yes
Approver attests that this user complies with all applicable HR on boarding processes
No Yes
Please check all that apply for whom access has been requested
Previously employed by Children's
Previously employed by UTSW or Parkland
Currently employed by UTSW or Parkland
Approver attests, if this user is to gain access to Sensitive or Restricted data, that they are bound by a confidentiality statement, either documented within the contract for services or Children’s Third Part Confidentiality Agreement.
No
Yes
Note: the STU number should be exactly as it is formatted in the IRB with dashes (-) appropriately placed (i.e., STU mmyyyy-xxx or STU-yyyy-xxxx
Examples shown below:
Research Monitor Visit for: Town > STU 012017-987
Research Monitor Visit for: Town > Deb Study > STU-2020-9876
Research Monitor Visit for: PI last name > Short title (ONLY if known) > STU number
Requested Access
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