Request for Review: Peri-Operative Services
Please complete this form as per the Capital Health (CH) mandate of identifying the impact of
research on clinical services. Once completed, please send to CH Research Services Office of
Contract/Grant Facilitation along with an e-copy of the protocol.
Process: The request will be forwarded to Karen Mumford, Director of Health Services, for
consideration and a decision on whether further review by the OR Finance Committee is required.
Queries, approvals and comments will be issued by co-leads of the relevant committee and/or Director
directly to the Principal Investigator.
Please be advised that as per this mandate, Research Budgets and Agreements will not be finalized
by Research Services until this form has been completed, submitted and approved.
To be completed by the Principal Investigator
Principal
Investigator:
Research
Coordinator:
Department:
Protocol Name
and/or No.:
Number of Patients
Expected:
Approximate Start
Date:
Title:
REB #
Phone:
Study Sponsor
Hospital Site:
Approximate End
Date:
Brief description of
study plan
Section 1
1. Will any requirement* of this study take place in the peri-operative portfolio?
(*includes standard of care procedures that must be completed in connection
with the Study protocol)
a)
b)
c)
d)
e)
Pre-admission
Operating Room
Post-anaesthetic care unit
Day surgery
Regional Block Room
Yes
Yes
Yes
Yes
Yes
No
No 
No
No
No
If you answered “No” to these questions, please proceed to Section 3 and sign the form
and submit it to Research Services.
If you answered “Yes” to one or more of these questions, please answer the questions
in Section 2, sign this form and submit it and an electronic copy of the protocol to
Research Services.
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Request for Review: Peri-Operative Services
Section 2
Please answer the following questions in order to identify the resources/expenditures
requested for this project involving CH peri-operative services which are outside standard of
care at Capital Health (CH). If additional space is required, attach a second page marked
Appendix A, along with a copy of the protocol.
1. Does the proposed study involve surgical interventions that are outside standard of care
at CH?
a) Yes
b) No
If yes, please provide details below.
2. Does this study have any peri-operative staffing impact?
a) Yes
b) No
If yes, please provide details below.
3. Does this study require new instrumentation or equipment to be reprocessed?
a) Yes
b) No
If yes, please provide details below.
4. Does this study require any additional surgical or laboratory supplies?
a) Yes
b) No
If yes, please list below with the accompanying costs.
5. Does this study involve new equipment to be held at Capital Health?
a) Yes
b) No
If yes, please provide any details.
6. Does the study budget cover any increase in medical/surgical/laboratory supplies,
equipment, instruments and devices, or drug costs involved in this study?
a) Yes
b) No
If no, please provide:
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Request for Review: Peri-Operative Services
I confirm that the provided information is accurate and based on my understanding of the
research protocol/study indicated above.
Principal Investigator
Name: _______________________
Date: _______________________
Committee Use Only:
We have reviewed the above noted request and based on information provided:
Approve
Approve with Conditions (below)
Not Approve
___________________________
Name (print and sign)
V7 - Revised June 2, 2014
_____________________
Date
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