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QIP Service Request Form
Requestor's Role
Principal Investigator
Co-Investigator
Project Manager
Research Coordinator
Research Assistant
IRB Staff
Requestor's Name
Requestor's Email
Requestor's Telephone Number
Principal Investigator's Name (if different from requestor)
Principal Investigator's or Primary Contact's Email (if completed by IRB Staff)
Department
HSPH- Center for Biostatistics in AIDS Research
HSPH- Environmental Health
HSPH- Epidemiology
HSPH- Genetics and Complex Diseases
HSPH- Global Health and Population
HSPH- Health Policy and Management
HSPH- Immunology and Infectious Diseases
HSPH- Nutrition
HSPH- Social and Behavioral Sciences
HSPH- Other
HMS- Academic and Clinical Affairs
HMS- Anesthesia
HMS- Biological Chemistry & Molecular Pharmacology
HMS- Cell Biology
HMS- Center for Biomedical Informatics
HMS- Center for Primary Care
HMS- Continuing Education
HMS- Countway Library
HMS- Dermatology
HMS- Diversity and Community Partnership
HMS- Division of Medical Ethics
HMS- Division of Sleep Medicine
HMS- Endocrinology
HMS- Faculty Affairs
HMS- Genetics
HMS- Global Health and Social Medicine
HMS- Harvard-MIT Division of Health Sciences and Technology (HST)
HMS- Health Care Policy
HMS- Medical Education
HMS- Medicine
HMS- Microbiology and Immunology
HMS- Neurobiology
HMS- Neurology
HMS- Obstetrics, Gynecology, and Reproductive Biology
HMS- Office for Postdoctoral Fellowship
HMS- Ophthalmology
HMS- Otology and Laryngology
HMS- Pathology
HMS- Pediatrics
HMS- Physical Medicine and Rehabilitation
HMS- Population Medicine
HMS- Psychiatry
HMS- Radiation Oncology
HMS- Radiology
HMS- Scholars in Medicine Office (student projects)
HMS- Surgery
HMS- Systems Biology
HMS- Wyss Institute
HSDM- Dental Education
HSDM- Developmental Biology
HSDM- Oral and Maxillofacial Surgery
HSDM- Oral Health Policy and Epidemiology
HSDM- Oral Medicine, Infection, and Immunity
HSDM- Restorative Dentistry and Biomaterials Sciences
Other
Harvard Longwood Medical Area IRB Protocol Number (if assigned)
Study Title
Requested QIP Services
Submission Assistance (review of application or electronic submission support)
Study Start-up Assistance
Routine Onsite Review
Regulatory Binder Consultation
External Audit Prep Assistance
On-site Monitoring
Floating Research Coordinator/ Project Manager Support
In-Serivce
New HLMA PI/Research Coordinator/Staff Orientation
Consultation
SPA Request For Consultation
Other
General Consultation/Additional Comments: Please specify
QIP In-Service: Please specify topic (if known)
Years participating in human research
0-1
1-5
5-10
Have you worked with QIP in the past
Yes
No
How did you hear about the QIP Service Request Process
OHRA Website
IRB Review Specialist
Colleague Referral
Other:
Upload any background documents here.
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