DEPARTMENT IMPACT STATEMENT

 

Study Title:                                                                

 

Principal Investigator:                                                        

Provide a statement that identifies what type of support is needed from each Immediate Supervisor for you to implement your research.

 

ADMISSION/IN-PATIENT EFFECTS:

 

In-Patients (#):              Estimated Admission Duration (Days):

 

SPECIAL REQUIREMENTS (indicate need or N/A)

 

Laboratory:

 

Pharmacy:

 

Radiology:

 

Nuclear Medicine:

 

Nursing Services:

 

Patient Administration:

 

Other:

 

APPROVALS:

 

                             

Principal Investigator's Immediate Supervisor

Name:

Rank:

Title:

 

IMPACT SIGNATURES:  Specify any difficulties your Department may have in providing the support requested.

 

 

                                                                    

Name:                                 Name:

Rank:                                 Rank:

Title:                                Title:

 

                                                                    

Name:                                 Name:

Rank:                                 Rank:

Title:                                Title: