Start-Up Report

Program Information (As Reported in the Project Submission)

Project Number (Assigned by DOH):

Hospital:

Hospital Operating Certificate Number:

Hospital Principal Contact:

Address:



Phone Number:

Fax Number:

E-mail:


I certify that the information contained in this report is true and accurate and complies with program requirements.

Principal Contact Signature: _________________________________________________ Date: _____________________

Project Title:

Sponsor/Mentor:

Address:



Phone Number:

Fax Number:

E-mail:


I certify that the information contained in this report is true and accurate and complies with program requirements.

Sponsor/Mentor Signature: _________________________________________________ Date: _____________________

Researcher Information (New Information Requested)
Name of Research Candidate:
Citizenship Status:
Name of Medical/Dental School Completed, Degree and Date:


Name of Residency Program:
Specialty:
Home Address:


Medical License / Limited Permit Number:
Start Date:
Number of Hours per Week in Research Position:
Name of Institution Review Board (IRB):
Date Project Approved by IRB:

Supplemental Information (Reference the Question these Changes Pertain to in the Project)
|Back to Top|