**Letters of Support for Research Projects**

**from** **VAPHS Service Chiefs**

** **

**Principal Investigators:**

Complete the top portion of the following Memo and forward with a copy
of your full research proposal to EACH of the services indicated as
essential institutional support for completion of your research project
(checked in \# 17, Request to Conduct Research,  Part I: R&D-Request to
Review). The Service Chief/representative will consider the impact of
your study on the Service, and respond accordingly. The R&D committee
cannot approve your study without an affirmative Memo of Support from
all necessary Services. A signature from the relevant Service Line Vice
President (or designee) is also required.

**[Service / and Relevant Service Line:]{.underline}**

*[(current contact information is available from the VAPHS web site
and/or the Medical Director's office)]{.underline}*

# 

# Laboratory / Clinical Support Service Line

Nuclear Medicine / Clinical Support Service Line

Pharmacy / Clinical Support Service Line

Radiology / Clinical Support Service Line

Medicine Services (Cardiology, Dermatology, Dialysis, ENT,
Gastroenterology, Hematology, Infectious Disease, Neurology, Oncology,
Pulmonary, Sleep Lab) / Medical Specialty Service Line

Nursing / Patient Care Service Line

Outpatient / Primary Care Service Line

Psychiatry / Behavioral Health Service Line

Surgery / Surgical Specialty Service Line

  

**DEPARTMENT OF** **VETERANS AFFAIRS**

**VA Pittsburgh Healthcare System (VAPHS)  **

(To complete this form, \'select all\', \'copy\', and \'paste\' into a
new Word document;  complete and submit to the Research Office)

**[MEMORANDUM: Request for Service Support for Research]{.underline}**

**To:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_Chief/Representative,**

**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_Service**

**From: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**,
**Principal Investigator**

**Research Project Title:**
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

1\. The Cooperation of the [     
\_\_\_\_\_\_\_\_\_\_]{.underline}Service is requested to accomplish the
goals and objectives of the above named research project.

2\. Please review the attached protocol of this proposed research study.
We will recruit approximately [     ]{.underline} patients over one
year. These patients will require the following procedures involving the
[      \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.underline}Service:

a\. [     ]{.underline}

b\. [     ]{.underline}

3\. These procedure(s) (check one) **[are]{.underline}** \_\_\_\_ or
**[are not]{.underline}** \_\_\_\_\_ solely for the purposes of this
research project.

4\. The cooperation of the \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Service will
be acknowledged in the acknowledgment section of any publications that
may arise from this study.

Please assess if the impact on your service is acceptable. This proposal
will be submitted to the R&D Committee once your approval is obtained.

 

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_

Principal Investigator's Signature Phone/contact information Date

 

 

  

**DEPARTMENT OF** **VETERANS AFFAIRS**

**VA Pittsburgh Healthcare System (VAPHS)  **

**[MEMORANDUM: Service Support for Research]{.underline}**

**To:** Associate Chief of Staff for Research (151-U)

**From:** Chief/Representative, [     ]{.underline} Service

**Subject:** Research Proposal (Title and PI Above)

[\_\_]{.underline} I have reviewed the above proposal and have
determined its impact will be of insignificant consequence to the [     
\_\_\_\_\_\_\_]{.underline} Service, which is willing to cooperate on
the study without compensation.

[\_\_]{.underline} I have reviewed the above proposal and, although it
requires minor financial support, the [     
\_\_\_\_\_\_\_\_\_\_]{.underline} Service is willing to cooperate on the
study without compensation.

[\_\_]{.underline} I have reviewed the above proposal and determined it
will be of significant cost to the [     
\_\_\_\_\_]{.underline}Service; financial reimbursement is requested at
the rate of \$ [     ]{.underline} for each of the [     ]{.underline}
patients. Reimbursement of service lines cannot be made to an individual
or an individual Veterans Research Foundation of Pittsburgh (VRFP)
account.

[\_\_]{.underline} The [      \_\_\_\_\_]{.underline} Service is not
able to accommodate the requirements of this study.

Other Comments:

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_

Chief/Representative's Signature Service Date

[Concurrence:]{.underline}

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_

Vice President/Designee's Signature Service Line Date