Submitted by:        Created:    Modified:    Brief title: RASCAL PT-TrakID #: What's this? Location: Columbia University IRB #: Dept chair: -- Select -- arm42 Andrew Marks crs2 Craig R. Smith dab2106 David Brenner drb25 David Bickers dwl1 Donald W. Landry eg2279 Evelyn C Granieri ehc1 Mark Byrne ehs79 Edward Shortliffe ess8 Ezra Susser fdc3 Frank Costantini fk5 Frederick Kass hms2 Henry Spotnitz ibl1 Ira Lamster jct8 Jeanette Takamura jl2616 Jeffrey A. Lieberman jsl12 James M. Lieberman lgc6 Lanny Garth Close lrs2155 Lawrence Stanberry lub1 Louis Bigliani mcb2 Mitchell Benson md511 Mary D'Alton mdg4 Michael Gershon mls7 Michael Shelanski mw218 Margaret Wood nes2 Nancy Strauss poa1 Philip O. Alderson pwb1 Paul Wesley Brandt-Rauf rap32 Richard Polin ras5 Robert Solomon rcs6 Richard Steinman rd10 Riccardo Dalla-Favera rpm2 Richard Paul Mayeux rs604 Ruchey Sharma rsk20 Robert Kass sc434 Stanley Chang sjs6 Saul Silverstein tap2 Timothy Pedley tcw21 Tim Wang Principal Investigator UNI: --Select-- aag1 aah2138 aas54 ab26 ab49 ac1044 ac699 ack2 ack6 acp10 adb2139 adc2121 adm4 aec79 aek4 aem1 aet1 agr3 ah2020 ahe2101 ahg1 ain1 ajf5 ajs8 ak493 akj3 akr7 alj4 als4 am2938 amc65 amd2 amm3 ams11 amv3 ap2138 ap390 ap504 ar127 ar2158 ard3 ard4 arm6 as20 as2276 as3576 as42 asg9004 asp7 az173 bas28 baz1 bd2137 bdw7 bf102 bf25 bhl2 bhs2 bl2185 bm44 bms12 bmt1 brr8 bs145 bs170 bs212 bs4 bt12 bt2160 btw1 bvw1 bzj1 ca2156 caa2105 cac3 cao2 cap6 cb116 cb2006 cb254 cb255 cbw7 cck27 ccm1 ccm2 ces2 cg278 ch28 ch439 chr2111 cjl18 cjr10 cjs3 ck2132 clc3 clg33 clk3 clw3 cme2109 cp2301 cpg2 crs2 cs600 csh1 cw345 cwb11 daa1 dab2106 daj3 db59 dc2105 dc2223 dcd1 dch3 dda18 ddm1 der2 df347 dg2039 dg2259 dgs5 dh17 dhs1 dis1 djc5 dji1 djk2123 djr2 dk2127 dkb3 dl349 dl427 dlb54 dld6 dlh23 dll20 dmb82 dmb9 dml1 dmm31 dpd3 dpp5 drb25 drs26 ds1012 ds2194 ds2231 dsd8 dsr1 dt2016 dv2029 dwl1 ea6 ead3 eam6 ear3 eb413 ed11 edl2 eel999 eg2279 eg45 ehk3 ejh3 el82 elc4 emh3 eo4 es207 es27 es54 esb14 esc5 esd1 ets1 evg1 evn2002 eyf2002 fae4 fg2124 fk11 fk5 fl189 fl2115 fm22307 fmq1 fo2108 fpp1 frl2 frs1 gba2 gd2140 gjf2 gjm2 gjt1 gln3 goo1 gr177 gr26 grb17 gs2184 gts2102 gw2128 gwn1 hb2133 hdb5 hdk3 hds1 hf2011 hf40 hff2101 hg2017 hhh1 hjw14 hlk2003 hm264 hms2 hng1 hr43 hr75 hs350 hsw1 hvt2106 ibl1 id71 if1 ijg3 im17 im2132 iss9 iv29 iz2123 ja2289 ja660 jae2 jal74 jal94 jam74 jar1 jar2 jbs21 jbs50 jc1031 jc2346 jc299 jc3110 jc47 jch150 jcl161 jcm5 jct2002 jd165 jda5 je111 jf2128 jf6 jfd2 jfm2111 jg176 jg589 jgs3 jha3 jhg1 jhh21 jhn2 jhp2 jim2 jj2023 jj2158 jjb4 jjg46 jjm0 jjw4 jk181 jk2848 jk32 jk467 jkg2101 jl175 jl2616 jl2674 jl2933 jl588 jl691 jlz2 jm2330 jm2456 jm669 jmd11 jmd4 jmg9 jmm23 jms5 jmz45 jnb2 jnf2 jp25 jp33 jp59 jpb2 jpd1 jpm10 jr1000 jr2024 jr2041 jr55 jrm6 js2106 js221 js2745 js3070 jsb106 jsj4 jss2128 jss7 jt165 jtb2 jtf38 jtg2 jw2459 jw2459 jw32 jw750 jw92 jwk18 jws6 jy2029 jzw1 kaf2 kas4 kb316 kck2002 kd2124 kd59 kfb2 kgn1 kh318 kha4 kk291 kl2356 klb1 klc2108 km208 kmp2 ko2032 kpp6 ksm1 kz38 laa2003 lag17 lao3 lap2 lc19 lc2193 ld394 ldl8 ler8 lfb9 lfi1 lg24 lg519 lh456 lhw1 lj2129 lja1 ljh3 ljm10 ll18 lls2 lm2242 lmd62 lmg57 lmq1 lpr1 lr2182 ls2353 ls38 ls5 ls731 lsl1 lss4 ma25 ma444 ma66 mad2037 maf2171 mah1 mah44 man2 mar2156 mas23 mb2358 mb2476 mb255 mb28 mb714 mbs4 mbs5 mc1310 mc2417 mcb2 mcg2 mcm2113 mcm2123 mco2 mcp73 md108 md42 md511 md785 mdb3 mdf10 meg18 mes52 mf2314 mf9 mfb1 mfc2003 mg2654 mg392 mg81 mgk7 mgm18 mgo1 mgs8 mh29 mi2193 mj2081 mjf3 mjh15 mjl2 mk2833 mk629 ml2398 ml653 mlk2 mlk32 mls95 mlw45 mm2058 mnb4 mp124 mp2429 mp2740 mp65 mpr2 mpw1 mr32 mr43 mr475 mrc1 mrf1 ms1027 ms2718 ms53 mse13 msm10 msn3 msr5 mt12 mt146 mt23 mt2348 mt760 mtf2 mty4 mvp19 mvs9 mw216 mw365 mwf6 mwg43 mwo1 myk2102 na2250 naf6 nb2217 nb343 nc18 nd2003 nd2058 njm2106 nk2125 nl2 nmd2108 nme3 nn45 np2199 ns2476 ns311 nss5 oc6 oo2130 paa5 pam15 pas3 pbr3 pbs1 pc2137 pcc2001 pcm6 pd23 pdf3 pds5 peh1 pf2105 pfs1 pg11 pg12 pg143 pg2011 pgg2 phg8 pjm5 pk88 pls1 pm125 pmm2002 poa1 pp16 pp192 ps2087 psd6 psl1 pt142 puf1 pwb1 ra3 ral22 ral35 ram7 rap32 rar7 ras5 rb43 rb464 rb540 rbk1 rbm3 rc18 rc395 rcb42 rde5 rdm3 reb10 red3 rf2013 rf2256 rf5 rff5 rg547 rg58 rgb9 rj216 rjb3 rjd20 rjg148 rjm1 rjw8 rkb1 rl13 rl207 rl232 rl272 rl351 rl356 rlb175 rld17 rlf1 rlf20 rlg11 rlm14 rls1 rls4 rlw3 rm2205 rm2266 rmr5 rms7 rn5 rns4 rnt1 rp242 rp296 rpm2 rps7 rr2172 rrg2 rs21 rs2463 rs543 rs62 rs66 rsc6 rsg2 rsm2 rsm3 rtd2106 rti3 rts1 rvh5 rw2191 rwd1 sa2059 sab8 sae2103 sam14 sb605 sbh22 sc1242 sc2752 sc42 sc434 sc56 sck33 sd12 sd45 sdc10 sdk8 sds2159 sek44 seo8 sf1 sf216 sf2246 sf2388 sg2203 sg2339 sh23 sh2395 shl24 shs51 sjl12 sjs4 sjs5 sjs9 sk2097 sk46 sk48 skl11 skv2001 sl11 sl2081 sl2420 slg8 slt3 sm1233 smh48 so2045 sp23 sp31 spc10 spe3 spr2 sr2327 sr747 srb40 sri1 srv2004 ss125 ss2341 ss35 sss74 st166 st326 sw189 sw22 sw2269 swn2 ta2107 tam1 tap2 tb211 tb2325 tcw1 td2142 tds1 th2135 tjc1 tjg1 tjs1 tln2001 tmg2108 tp2114 tpj1 tr2171 tr89 ts259 tsr1 tt18 tw2131 upj1 vad1 vrg2 wah1 wbi2102 wch2 wfy1 wg131 wg2131 wh148 whs4 wk2106 wkc15 wm143 wmg1 wms13 wnl1 wp56 ws2157 wsb2 wt60 ww42 yc70 ye1 yn33 ys11 zas1 zfl1 zh50 Name: Telephone: Cell or pager: E-mail: Clinical Coordinator UNI: Name: Telephone: Cell or pager: E-mail: 1. Funding: Is the research sponsored (either directly or with flow-thru funds) by either federal, state, or local government? (If "Yes", go to question 8. Otherwise, go to question 2.) No Yes 2. The following questions relate to clinical trials and drug or device studies only. 2a. Is the research a clinical trial being done for FDA approval for marketing of a new drug, or for the approval for a new indication for an already-approved drug? No Yes 2b. Will the research provide direct benefit to the participants that would not be available outside of the research? If the answer to "2a" is "Yes" and "1" is "No", go to Number 8. If the answer to "2a" is "No", go to Number 3. No Yes 3. Does the work require scientific expertise on the part of the Columbia University Investigator as opposed to repetitive work or routine testing? No Yes 4. Does the testing add knowledge within a scientific field (verses testing for quality control for certification purposes)? No Yes 5. Is the research scientific in nature? Check "Yes" if EITHER question 3 or question 4 is "Yes". Otherwise check "No". No Yes 6. Is the scientific research conducted for the public interest (complete items 6a through 6e)? 6a. Research results will be made available to the public? No Yes 6b. Research aids in discovering a cure to a disease? No Yes 6c. Research aids in developing or retaining industry in the area / community? No Yes 6d. Research is directed toward benefiting the public? No Yes 6e. Research aids in scientific education of university students or house staff? No Yes 7. If any item within Number 6 is marked YES, please provide a brief statement explaining "WHY" or "HOW" the research is scientific and in the public interest. (Please do not describe what the research is). 8. Thank you for your time and efforts in completing this form. I understand that this form is used as a decision tool to help distinguish whether sponsored research activities are related or unrelated taxable business income. I also understand that the initial decision regarding the classification of the sponsored research will be made relying upon the conveyed through this form. However, the decision made could be refuted by the IRS. I certify that all information provided above is accurate and complete to the best of my knowledge. Disagree Agree Form is not yet complete.  Do not yet forward information to Clinical Trials Office. Form is complete.  Forward information to Clinical Trials Office.