Request an Appointment for Monitoring the Research Study

Please fill out the form

* Visit Type:

* IRB Number:

If No IRB Number, please Type PENDING.

* Principal Investigator:
* Point of Contact:
* POC Phone:
* POC Email:
* Name Of Monitor:
* Appointment Date:
* Appointment-Start Time:
* Appointment-End Time:
   
*Review Site:
Pharmacy Radiology
Lab Medical Records
UHS Monitor Room Coordinator's Office
Other
   
Additional Info/Comments:
Please note:
  1. Application for access to electronic records requires completion of the UHS Confidentiality forms(UT Employees and Research Monitor).
  2. Hard Copies of records must be requested three days prior to the visit, medical records CANNOT leave UHS.
  3. If patient contact is needed, monitor/vendor will need to go through the Symplr process, guaranteeing all UHS competencies and immunization/drug test requirements have been met. Access Symplr at http://signup.symplr.com/template/template2/index.php and indicate University Health System. There is a fee associated with the process.
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