Online Notification Tool

Abbreviated Study Title:

Study Type: Drug Device Emergency HDE Other

IRB # :
PI Name (Last, First):
Coordinator Name:
Coordinator Phone:
Coordinator Email:
Notification Type:

If Notification Type is Adverse Event. Please answer questions below; otherwise, skip to Question 7.

Study Related: Yes No
Date of Adverse Event/Admission:
Description of AE (please limit to 500 characters)
Resolved: Yes No

TGH Medical Record # :
Patient Name (Last, First):
Patient DOB (mmddyy):
Patient's Insurer:
Date of service/Enrollment (mmddyy):
Please provide any further comments you feel will assist OCR (please limit to 500 characters)

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