Page 286 - eBOOK VERSION 8 BOOK 2 of 2 JUL 2022

Department of ______________ Date: ____________________
NOTICE OF _______________________________SERVICES APPROVAL
Dear Investigator/Requestor,
The Department of ________________________ at Children's HealthSM has reviewed and approved the following requested services in support of your research activity:
Approval Number: _____________________ Approval Date: _____________
Study Title: _______________________________________________________________ Principal Investigator: _______________________________________________________ Primary Research Coordinator: _______________________________________________ IRB#: _______________________
Velos#: _____________________
Documents Reviewed:
Protocol, Version: _______________
Investigator Brochure, Version: ______________ Manual of Operations, Version: ______________ Manual of Procedures, Version: ______________ Lab Manual, Version: ______________________ Pharmacy Manual, Version: _________________ Imaging Manual, Version: ___________________ Any Other: _______________________________
Services Identified:
Name of Service:
Procedure Code
# of Times to be performed
Visit to be performed
Does the protocol require staff member to be trained?
__________________ _________________ Name Signature
Yes / No
____________________ Date
Note: No changes can be made to the services listed above without review/approval by ________________.