Clinical Trial Budgets - Excel by uhg16263

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									IBED Revision Request                                                                                     Request to Revise Chartfield for Existing Clinical Trial Study/Industry-Sponsored Project
                                                                                                  Submit signed copy to: Office of Industry Contracts, MedCenter One, 501 E. Broadway, Suite 200, Louisville, KY 40202-1798
(Investigator, Budget, End Date)                                                                                               To submit signed copy electronically, search GroupWise for Industry Contracts, Service Account


PROJECT IDENTIFICATION (Required for all requests)
                                                                                                                                                 Study Title/
                 Chartfield Number                                         Sponsor Name (1)                                                      Protocol (2)

           REQUEST FOR BUDGET REVISION (Complete this section if applicable)

                                                                                                                                                                           Comments/Reason for Revision (5)
                                                                            Current                    New Requested                                                  (If clinical trial, total number of subjects now
                                          Account Pool (3)               Budget Amount                 Budget Amount                     Difference (4)                            expected to be enrolled)
                                                                                                                                                          $0.00
                                                                                                                                                          $0.00
                                                                                                                                                          $0.00
                                                                                                                                                          $0.00
                                                                                                                                                          $0.00
                                                                                                           Total Difference:                              $0.00

           REQUEST FOR END DATE EXTENSION (6) (Complete this section if applicable)
                                          Current Begin Date:
                                              Current End Date:                                       Requested End Date:

           AUTHORIZATION FOR CHANGE OF PI (7) (Complete this section if applicable)
                                                    Current PI:                                                       New PI:
                                                                  Provide RIF percentage and         % Collaboration (RIF):
                                                                  percentage effort for new PI.
                                                                                                                     % Effort:                                              Effective Date:

CONTACTS AND SIGNATURES (Required for all requests)
                        Prepared by
                                       Name                                                       Date                            E-mail address                                                Phone Number
               UBM/CFM review (8)
                                       Name                                                       Date                            E-mail address                                                Phone Number

           By signing this form, the undersigned Principal Investigator(s)/Co-Investigator(s) and Department Chair(s)/Unit Head(s) understand that they are responsible for the budget requested above and any
           deficits or uncollectible costs per sections 6.4 and 6.9 of the Research Handbook. Signature(s) of departmental authority at a higher level than the PI required.


     Contact/Principal Investigator
                                       Name                                                       Date                            Signature
     Multiple or Co-Investigator (9)
                                       Name                                                       Date                            Signature
                      Unit Head (10)
                                       Name                                                       Date                            Signature
              Department Head (10)
                                       Name                                                       Date                            Signature
                  Dean's Office (11)
                                       Name                                                       Date                            Signature


3aaa34b6-a558-4ba8-b3df-379fe56de7da.xls Revised 03/15/2008                                   Printed 1/5/2011 7:40 PM                                                                                                Page 1
See URL for instructions in completing the budget portion of this form:
http://louisville.edu/research/offices/industry-contracts/clinicalresearchservices/sponsors/Budgeting-Industry-Sponsored-Clinical-Trial-Budgets-at-UofL.doc

Form comments/instructions:
(1) Enter name of sponsor of study.
(2) Please include either short title of study or protocol number of research.
(3) Complete this column with budgetary pool account (example: 511000 salary pool) only if transferring funding from one pool account to another.
(4) Calculated field - do not enter.
(5) Example: Currently xx subjects/patients enrolled, expect to enroll yy new patients at $zz.zz per patient; Sponsor expanded scope per amendment z.
(6) Enter current begin and end dates, and new end date. Attach sponsor approval if applicable.
(7) Enter current PI, new PI, and percent collaboration and percent effort for new PI. Enter effective date for PI change. Attach sponsor approval if applicable.
(8) Complete as applicable for particular unit. Used to indicate change has been reviewed by business administrator/clinical financial manager.
(9) Complete as applicable for particular study. Copy and repeat additional lines if needed.
(10) Complete both unit head and department head only if different individuals for your unit.
(11) Dean's signature required if an individual budget account increase or total budget increase for all accounts is $150,000 or greater.




3aaa34b6-a558-4ba8-b3df-379fe56de7da.xls Revised 03/15/2008                                    Printed 1/5/2011 7:40 PM                                             Page 2

								
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