Request an Appointment for Monitoring the Research Study

Please fill out the form

*IRB Number:
*Principal Investigator:
*Name of Contact Person:
*Contact's Phone/Pager:
*Contact's Email Address:
*Name of Monitor:
*Monitor's Phone/Pager:
Medical Records Activity:
Need Med. Rec. Training?
Appointment Date:
Appointment-Start Time:
Appointment-End Time:
   
Please note:
  1. Fields marked by an "*" are required.
  2. Application for access to electronic records requires 5 business days (click HERE to download the appropriate access request form).
  3. Hard Copies of records must be requested 3 days prior to the visit.
  4. Records cannot leave the building.
   
Pharmacy Activity:
Appointment Date:
Appointment-Start Time:
Appointment-End Time:
Review Site:
Additional Info/Comments: