Pathology Collaboration Agreement
Approved by: Yvonne Myal
Signature on file
Effective Date:
19-JUL-2011
Document #
F170-120-01C
Version # 03
Source Document:
Research Policy
170-120-01
Research Study Title:
Sponsor Protocol Number (as provided by Principal Investiigator) :
Disease Site Group:
Number of Cases Expected:
Deliverables Requested:
____________________________
Signature of Principal Investigator
_________________________
Printed Name
______________
Date (dd/mm/yyyy)
Note: Pathologist’s time will be billed at a minimum charge of $35/10 minute interval.
Collaborating Pathologist Statement of Responsibilities:
As the Collaborating Pathologist for the above named clinical trial or research project, I am aware of the
tissue requirements outlined in this protocol, agree to be the main pathology contact person in
collaboration with the Principal Investigator, and will be responsible for the selection of tissue
(blocks/slides) to be released.
Terms of Agreement (check applicable boxes and provide details):
1.
Research as part of non-clinical workload
2.
Research work in lieu of clinical workload, as approved by U of M Pathology Department Head
3. Time Estimate:
/ per case
_______________________________
Signature of Collaborating Pathologist
_________________________
Printed Name
______________
Date (dd/mm/yyyy)
Approval from Pathology Medical Director (or designate):
___________________________________
Signature - Dr. John Gartner
_____Dr. John Gartner_________
Printed Name
________________
Date (dd/mm/yyyy)
Diagnostic Services of Manitoba’s vision is to provide a high-quality, state-of-the-art diagnostic system for Manitoba that is known
for its excellent customer service and which is centrally managed, cost-effective and sustainable.
Website www.dsmanitoba.ca
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