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Request an Appointment for Site Qualification, Site Initiation, Site Close-out, Monitoring Visit, or
Compliance Visit (UT, or Other)
Please fill out the form
*
Visit Type:
Site Qualification
Site Initiation
Site Close Out
Monitoring - No Patient Contact
Monitoring - Patient Contact(requires Symplr)
Compliance Visit (UT, or Other)
*
IRB Number:
If No IRB Number, please Type PENDING.
*
Principal Investigator:
*
Point of Contact:
*
POC Phone:
*
POC Email:
*
Name of Representative:
*
Name of Representative Email:
*
Appointment Date:
*
Appointment-Start Time:
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8:00am
8:30am
9:00am
9:30am
10:00am
10:30am
11:00am
11:30am
12:00pm
12:30pm
1:00pm
1:30pm
2:00pm
2:30pm
3:00pm
3:30pm
4:00pm
4:30pm
*
Appointment-End Time:
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8:00am
8:30am
9:00am
9:30am
10:00am
10:30am
11:00am
11:30am
12:00pm
12:30pm
1:00pm
1:30pm
2:00pm
2:30pm
3:00pm
3:30pm
4:00pm
*
Review Site:
Pharmacy
*
Location
University Hospital
Robert B. Green Campus
Texas Diabetes Institute
Other
*
Other, please fill in below:
*
Times
30 Minutes
1 Hours
1.5 Hours
Other
*
Other, please fill in below:
Radiology
*
Location
University Hospital
Robert B. Green Campus
Texas Diabetes Institute
UHS-MARC
Other
*
Other, please fill in below:
*
Times
30 Minutes
1 Hours
1.5 Hours
Other
*
Other, please fill in below:
Lab
*
Location
University Hospital
Robert B. Green Campus
Texas Diabetes Institute
Other
*
Other, please fill in below:
*
Times
30 Minutes
1 Hours
1.5 Hours
Other
*
Other, please fill in below:
UH Research Department Monitoring Room
*
Times
30 Minutes
1 Hours
1.5 Hours
Other
*
Other, please fill in below:
Coordinator's Office
*
Times
30 Minutes
1 Hours
1.5 Hours
Other
*
Other, please fill in below:
Other
*
Times
30 Minutes
1 Hours
1.5 Hours
Other
*
Other, please fill in below:
Additional Info/Comments:
Please indicate any specific information that can assist with the request
Please note:
Application for access to electronic records requires completion of the UHS Confidentiality forms(UT Employees and Research Monitor).
Hard Copies of records must be requested three days prior to the visit, medical records CANNOT leave UHS.
If the representative is wanting to go into any patient area that the general public cannot go into within any location throughout University Health System, the representative will REQUIRE Symplr credentialing this process guarantees all UHS competencies and immunization/drug test requirements have been met. Please access Symplr through the website:
http://signup.symplr.com/template/template2/index.php
and select "All Access", and in the "What facility referred you?" please indicate University Health System – (location): San Antonio, TX. There is a fee associated with the process.
This form is being filled out by a human being:
