The code block below illustrates how one might use # and // as comments in your logic and calculations.

This value you provided is not a number. Please try again.

This value you provided is not an integer. Please try again.

The value entered is not a valid Vanderbilt Medical Record Number (i.e. 4- to 9-digit number, excluding leading zeros). Please try again.

The value you provided must be within the suggested range

The value you provided is outside the suggested range

This value is admissible, but you may wish to double check it.

The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).

This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.

This field must be a 10 digit U.S. phone number (like 415 555 1212). Please re-enter it now.

This field must be a valid email address (like joe@user.com). Please re-enter it now.

The value you provided could not be validated because it does not follow the expected format. Please try again.

Required format:

OCR Contract Intake Form

Thank you for contacting the OCR Contracting Group.

To submit a new contract, or to modify an existing one through an amendment, please complete the following form:

What is the study's contract ID? Please use the format: SPONSOR_PI NAME_PROTOCOL #

Are you submitting a new contract intake form, or an amendment for an existing contract?

* must provide value

New Contract Intake Amendment

reset

Contract Amendment

Please describe a brief summary of the requested amendment:

* must provide value

Expand

Principal Investigator Contact Information

Principal Investigator Name:

* must provide value

Department:

Address:

* must provide value

Expand

Phone:

* must provide value

Is the Principal Investigator an employee of Indiana University?

* must provide value

Yes No

reset

What is the PI's IU Faculty Status?

* must provide value

Faculty

Adjunct

Affiliate

reset

Please define the PI's employer:

* must provide value

IUHP

IUMG

SIP

Other

reset

Please specify the PI's employer:

* must provide value

Name:

* must provide value

Title:

* must provide value

Phone:

* must provide value

Email:

* must provide value

Research Site:

* must provide value

Sponsor Contact Name:

Sponsor Contact Phone:

Sponsor Contact Email:

Contract Information

Is this a 3 Party Contract?

* must provide value

Yes No

reset

Is there already a Master Agreement?

* must provide value

Yes No Unknown

reset

If available, upload the Master Agreement or Master Agreement template

Upload file

Type of Agreement:

* must provide value

Clinical Trial Agreement/CTA

Letter of Agreement/LoA

Master Agreement

Other

Please specify other agreement:

* must provide value

Are additional agreements needed?

* must provide value

Yes No

reset

If yes, please list. (For subcontracts, please provide contact information and scope of work)

* must provide value

Expand

Participating Sites

Will this study be conducted at more than one site, or will there be a possibility that additional sites will be added later?

* must provide value

Yes No

reset

Which sites will be included in the study, or may be included in the future?

* must provide value

IU Health Methodist Hospital

IU Health University Hospital

IU Simon Cancer Center

IU Health North Hospital

IU Health West Hospital

IU Health Arnett Hospital

IU Health Ball Memorial Hospital

IU Health Bloomington Hospital

IU Health Saxony Hospital

Other

Please state which other sites you intend to include:

* must provide value

Expand

Will the other participating sites require individual work orders?

* must provide value

Yes No

reset

To facilitate work orders for each site, please provide the email for each site's contact. We will reach out to each site to begin their individual work order.

Email for IU Health Methodist Hospital work order contact:

Email for IU Health University Hospital work order contact:

Email for IU Simon Cancer Center work order contact:

Email for IU Health North Hospital work order contact:

Email for IU Health West Hospital work order contact:

Email for IU Health Arnett Hospital work order contact:

Email for IU Health Ball Memorial Hospital work order contact:

Email for IU Health Bloomington Hospital work order contact:

Email for IU Health Saxony Hospital work order contact:

Email for the 'other' sites:

Expand

Any additional information that may be important to know about the other sites, or about the work orders for the other sites?

Expand

Funding

Who will be the Payee for work done under contract?

* must provide value

Expand

Please check the appropriate boxes indicating the funding source for your research:

* must provide value

Internal

Federal Agency

Foundation

Corporate

State Agency

Other

If your funding source is not internal, please enter the name of the sponsor and the study protocol number

* must provide value

Expand

Do you expect the proposed research to generate patent applications or other intellectual property, or create anything of commercial value?

* must provide value

Yes No

reset

Will IU School of Medicine be involved with conducting the study?

* must provide value

Yes No

reset

Informed Consent

Upload file

Letter of Agreement/LoA

Upload file

Letter of Indemnification

Upload file

Protocol

Upload file

Proposed Budget

Upload file

Clinical Trial Agreement/CTA

Amendment

Other attachment

Other attachment 2

Other attachment 3

Other attachment 4

Other attachment 5

Please include any additional information that would aid us in processing this agreement:

Expand

You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.