BAPTIST MEDICAL CENTER - Baptist Health



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INSTITUTIONAL REVIEW BOARD

PROTOCOL SUBMISSION CHECKLIST FOR DOWNTOWN

NAME OF STUDY SPONSOR GRANTING AGENCY:

TITLE OF PROJECT:

PRINCIPAL INVESTIGATOR (PI):

RESEARCH COORDINATOR/TELEPHONE/EMAIL:

MAILING ADDRESS:

PI EMAIL ADDRESS:

This form must be completed and submitted at the time of protocol submission to the IRB. Prior to review by the IRB, you will need to complete and email this form along with the required attachments to the IRB email, ircsubmission@ and to BHRC email, bhrcsubmissions@. Please refer to IRB Policy No. 1.1 “Guidelines for Protocol Submission” and BH 2.6 “Baptist Health Research Institute (BHRI) Protocol Submission Approval (PSA)” for further information regarding your responsibilities as a Principal Investigator.

This section is to identify those health system resources that will be required for this research project and are not part of standard patient care. Please check all that apply:

Department Name Phone # Email Address

□ Laboratory Darlene Fletcher 202-1517 mary.fletcher@

□ Microbiology Terre Smith 202-2192 terre.smith@

□ Pharmacy Marjorie DeLucia 202-3303 marjorie.delucia@

□ Patient Financial Services Mae Poston 376-4171 mae.poston@

□ Cath Lab Robin Davison 202-9280 robin.davison@

□ Radiation Safety Committee David Hernandez 202-1452 david.hernandez@

□ Surgical Debbie Hickman 202-3205 deborah.hickman@

□ Emergency Department Jonathan Allen 202-9144 jonathan.allen@

□ Radiology/Nuclear Medicine Kim Hurse 271-6152 kimberly.hurse@

□ Heart Hospital Nancy Marlett 202-1298 nancy.marlett@

□ Neurology/Weaver Jennifer Crews 202-3580 jennifer.crews@

□ BMDA Kimberly LaBree 202-7359 kimberly.labree@

□ M/S Critical Care/Ortho/

Dialysis/Venous Access Blanca McKean 202-1389 blanca.mckean@

□ Women’s Services Cicely Brooks 202-2162 cicely.brooks@

□ Quality Administration Dawn Smith 202-2341 dawn.smith@bmcjaxcom

Nursing:

□ Adult Nursing Division Peggy McCartt 202-1769 peggy.mccartt@

□ Wolfson Nursing Division Amanda Brown 202-3258 amanda.brown@

□ Education Liz Bruno 202-1499 elizabeth.bruno@

□ Not Applicable

For those areas marked above, it is the responsibility of the Principal Investigator or Study Coordinator to contact each Director to discuss the impact this research project will have on their department. A copy of the protocol must be submitted to the designated person for each department to be involved in this study so that they can determine their departments’ ability to perform the part of the protocol that they will be involved with. By signing your name below, you are attesting that the appropriate communication has taken place.

If the research study is going to affect the standard billing practices, it is also the responsibility of the Principal Investigator or Study Coordinator, to contact the Director of Patient Financial Services, whenever a new patient is enrolled in this project. By signing your name below, you are acknowledging that you have fulfilled this responsibility.

Signature of Principal Investigator or Study Coordinator Date

Print Name

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