RASCAL PT-TrakID:  Brief title: 
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Study Title: 
Principal Investigator
UNI: 
Name: 
Telephone: 
Pager: 
E-mail: 
Sponsor:   

Please use the following form to elaborate on the contributions of this clinical research to the advancement of the educational and scientific clinical research missions of the University and the Hospital and the promotion of public health, which is required to support our tax-exempt status.

1.
Is the clinical research purpose of this study described in the protocol and IRB materials?
Yes      No
  If No, briefly describe the research question to be answered:
       
2.
This clinical research is intended to aid in:
please check all that apply
 
A.
 Diagnosis
B.
 Treatment
C.
 Increasing scientific knowledge about:
  disease or condition:
3A.
Will this clinical research aid in the educational mission of the University and the Hospital?
Yes      No
  If No to question 3A, there are no further questions:
3B.
If Yes to question 3A, will it act as practical experience in clinical research for medical students, interns, residents and/or fellows?
Yes      No
 
then continue to:
i                 ii
i.
If Yes to question 3B above, what role will they play?
please check all that apply
 
A.
 Patient Care
B.
 Data Collection
C.
 Data Analysis
D.
 Abstract/Publication Preparation
E.
 Reporting & Disseminating Results to Other Students & Faculty
F.
 Other:
  describe:
ii. If No to question 3B above, how will this clinical research aid in the educational mission?
       

We encourage you to provide the Clinical Trials Office with copies of any abstract, paper, or publication presenting the results of this study.

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