Investigational Pharmacy Service (IPS) Protocol Planning Worksheet
Sponsor:
Protocol number:
IRB Number
IRB Number
Please select
BMC-BU IRB
Central
Other
Comments:
Principal Investigator:
Name:
Phone#
Study Coordinator:
Name:
Phone#
Form Entered by:
Name:
Phone#
Department:
Please select...
Alzheimers Disease Center
Amyloidosis Center
Anatomy & Neurobiology
Anesthesiology
Arthritis Center
Biochemistry
Biomedical Mass Spectrometry, Center for
CReM - Regenerative Medicine, Center for
Cancer Care Center
Clinical & Translational Science Institute
Dermatology
Emergency Medicine
Epidemiology Bioscience
Family Medicine
Framingham Heart Study
Gastrointestinal Surgery
Medical Education
Medicine
Microbiology
National Emerging Infectious Disease Lab
Neurology
Neurosurgery
Obstetrics / Gynecology
Ophthamology
Oral and Maxillofacial Surgery
Orthopedic Surgery
Otolaryngology - Head and Neck Surgery
Pathology and Laboratory Medicine
Pediatrics
Pharmacology & Experimental Therapeutics
Physiology and Biophysics
Proteomics
Psychiatry
Pulmonary Center
Radiation Oncology
Radiology
Rehabilitation Medicine
Slone Epidemiology Center
Surgery
Urology
Whitaker Cardiovascular Institute
Division:
Please select...
Amyloid Research and Training Program
Biomedical Genetics
Calcium Signaling Unit
Cardiology
Clinical Epi Research and Training
Computational Biomedicine
Endocrinology, Diabetes and Nutrition
Gastroenterology
General Internal Medicine
Geriatrics
Hematology and Medical Oncology
Infectious Diseases
Medicine
Nephrology
Preventive Medicine and Epidemiology
Pulmonary, Allergy and Critical Care
Rheumatology
Vascular Biology
Vitamin D Lab
Division:
Division:
Please select...
Stroke
Division:
Please select...
General Obstetrics
General Gynecology
Gynecological Oncology
Maternal-Fetal Medicine
Division:
Please select...
Orthopedic Surgery
Pediatric Orthopedic Surgery
Division:
Please select...
Pediatric Adolescent Clinic
Pediatric General
Pediatric Infectious Diseases
Division:
Please select...
Acute Care and Trauma Surgery
Cardiac Surgery
Colon and Rectal Surgery
General Surgery
Pediatric Surgery
Plastic and Reconstructive Surgery
Podiatry
Surgical Critical Care
Surgical Endocrinology
Surgical Oncology
Thoracic Surgery
Transplant Surgery
Vascular and Endovascular Surgery
Documents Submitted:
Protocol/Draft (required)
Pharmacy Manual
Investigator Brochure
Other
Please upload the documents submitted (1):
Please upload the documents submitted (2):
Please upload the documents submitted (3):
If other, please specify:
Information requested from IPS:
IPS budget estimate
Cost of ancillary medications/supplies
Other
If other, please specify:
Provide IPS with name(s) and quantities of ancillary medications/supplies being requested:
Study information:
How many subjects are you planning to enroll?
Anticipated start date:
Funds managed by:
BUMC
BMC
Overall study duration (months/years):
Clinic/hospital location for study drug administration:
24/7 Pharmacy coverage requested
yes
no
If yes, please provide further details:
Other comments/queries:
