Research Affiliate Visitor Forms for PI/Managers

Transcription

1 Research Affiliate Visitor Forms for PI/Managers Page 1 of 5

2 Bar Code Identification Form Please print clearly Last Name First Name Address Affiliation (school or organization) Department Name Job Title Phone Number (hospital ext.) Start Date End Date (mandatory) Area(s) of access (PI or manager must initial each entry) Research Visitor - Affiliate Area Name Floor Wing Initial PI/ Manager Name (Print) PI/ Manager Signature For renewal only: reason why visitor is being renewed beyond initial end date (1 year max): For Office use only Access Card Number Not Paid by St. Michael s Hospital. Page 2 of 5

3 Research Affiliate Visitor Assignment Form for PIs/Managers Please complete all fields. It is the Investigator s responsibility to ensure space adequate training and supervision are available to support the research visitors work. PI Name: Program Manager: (If applicable) Start Date: Phone Ext: Phone Ext: End Date: Please describe why you are engaging this visitor and what they will receive from the experience: Please describe the specific duties of the visitors: Please describe all relevant skills or qualifications relevant to the duties: Will the visitor be working with biological material? Yes No If yes, please Steven Hayes at hayess@smh.ca to follow up on nextsteps. Is there any additional training beyond the standard training (i.e. Biosafety, WHIMS,etc.) required? Which days and what hours will the research visitor be expected to work? Where willthe research visitor be located? Please describe how the visitor will be supervised. Will the visitor interact with research subjects and/or patients, patient/research data and/or patient/research subject samples? Yes No * Please be reminded to read the prohibited activities in section 1.8 of the Research Volunteer and Visitor Policy If yes, have you informed or contacted the Research Ethics Board? Yes No What institution is the visitor affiliated with: What is the visitor s role or job titled at the affiliated Institution: Page 3 of 5

4 ill the visitor receive compensation or reimbursements directly from St. Michael s Hospital? Yes No If yes, please explain. Conflict of Interest Disclosure Is the individual a family member of the supervisor (or the individual responsible for the decision to engage this incumbent)? Yes No Is the individual affiliated with an organization in which the supervisor or the supervisor s family member has a financial or ownership interest? Yes No (Family Member includes a spouse, domestic partner, child, parent, sibling, grandparent, grandchild or other close relation. For the purpose of this policy (i.e., Research Conflicts of Interest), a family relationship includes biological relationships, adoptive relationships, relationships created through marriage and other relationships in which care-giving or dependency exists. Please note that if you check Yes, before this hire can be processed this information will be forwarded to the Office of Research Administration for review under the Research Conflicts of Interest Policy) Will the research visitor be exposed to clinical activities (e.g. patient contact) and/or exposed to human blood/body fluids? Yes No *If yes, the volunteer is required to complete the Corporate Health and Safety forms in the student package. If no, the volunteer is not required to complete the Corporate Health and Safety forms. Investigator/Manager Signature Date Signed (MM - DD - YYYY) - - Visitor Signature: Date Signed - - (MM - DD - YYYY) Page 4 of 5

5 Research Affiliate Visitor Service Agreement The supervisor/pi agrees to: Please read carefully before signing! Please check each box to acknowledge your understanding and agreement. Adhere to all responsibilities outlined in section 1.8 of the Research Volunteer and Visitor Policy (see excerpts in Instruction Sheet) (link to full policy: Provide supervision, training, orientation, supervision and feedback to the visitor specific to their work area/field Be accessible to the visitor for input, direction and to share information The research visitor agrees to: Seek direction from supervisor if visitor is unsure Always wear ID badge to be clearly visible Know the infection control guidelines and understand the importance of hand washing Not to exchange contact information including address, phone numbers, or social networking information with patients, study subjects and/or their friends and family. Maintain confidentiality Review the Research Volunteer and Visitor Policy and other relevant SMH policies within 30 days of start date I Understand and accept the terms of the foregoing Research Visitor Service Agreement. Date: - - Date: - - PI/manager (print) name: Research Visitor (print) name: PI/manager Signature: Research Visitor Signature: Page 5 of 5