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. V7 - Revised June 2, 2014 Page 1 of 3 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: V7 - Revised June 2, 2014 Page 2 of 3 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 Page 3 of 3