2016 Point-prevalence survey for antimicrobial resistance
in Canadian hospitals
Please complete this form and return by November 1, 2015 to Philippe
Martin
FAX: 416-480-6990 or email: philippe.martin@sunnybrook.ca
Hospital name:
City/Province
_____________________________________
Our hospital is interested and willing to participate in this survey in Feb 2016:
Yes [ ]
No
[ ]
If Yes,
[
[
] We will NOT need to submit this protocol to our REB
] We will be submitting the protocol for institutional REB approval:
Estimated date that review will be complete: ________________
We will require assistance with REB submission:
Yes [ ]
No [ ]
Not sure [ ]
[
] We are still investigating whether the project needs REB approval, and will
let you know if we need help to have review finished before November
Contact information (for the person taking responsibility for participation in this
survey):
Name:
Position:
Telephone:
FAX:
e-mail:
Mailing address:
Thank you very much for your interest and consideration!