Request to Use Hospital Equipment & Resources for Research Projects
1. Type of request
 Waiver of all costs related to equipments & materials
 Reduction of all costs related to equipments & materials
 Waiver of costs related to equipments only
 Waiver of costs related to materials only
 Reduction of costs related to equipments only
 Reduction of costs related to materials only
2. General Information
PI’s Name
Department
Protocol Name
IRB Protocol Number
IRB approval status
Study starting date
Expected ending date
3. Equipment /resources to be used
Type of equipment/resources
Department
Frequency of use per subject
Duration of use per subject
Number of subjects
Comments
4. Test & materials to be used
Cost per test
Code of test
Are there any disposable items
to be used in the test?
 Yes
If yes, please list:
 No
Codes of disposable items (if
known)
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5. Human Resources
Is there any clinical staff involvement?
Number of involved clinical staff
How you intend to Manage staff time
between clinical care & research tasks?
Please Comment
Is there any compensation for staff?
Amount of compensation
How are you planning to cover this
compensation?
 Yes
 No
 Yes
 No
 Partial
 None
6. Funding resources
Do you have any type of funding
resource?
Name of funding resource
Amount of available funding
7. Endorsement of the service Department Chair
 Yes
 No
Name & signature of the Department Chair: -------------------------------------------8. Hospital administration Decision
 Approval for:
 Waiver of all costs related to equipments & materials
 Reduction of all costs related to equipments & materials
% reduction --------or New rate---------- Waiver of costs related to equipments only
 Waiver of costs related to materials only
 Reduction of costs related to equipments only
% reduction --------or New rate---------- Reduction of costs related to materials only
% reduction --------or
New rate---------- Disapproval
Comments: ---------------------------------------------------Signature: ------------------------------------------------------
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