Statement of Account Request Letter Sample by ehp17932


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                            NEW RESEARCH AND TRUST ACCOUNT REQUEST

    Forward to:


    Please complete the form and attach all documents listed in the checklist below. The account set up process
    will be complete within 9 business days of receipt of the completed package.

    IMPORTANT: Missing documents from the checklist below will result in a delay, you will receive an e-mail
    identifying what is missing in order to proceed.

     Contract/Award Letter
      A signed copy of the industry or government sponsored funding agreement/contract is required to be completed in order to
      open a new research account
      Please provide OIRS Control Number __________ (i.e. 2011-XXXX)
      If the contract is not available, include one of the following:
      Letter of Intent AND original application; Funding Letter; New Investigator Fund award letter

     Research Ethics Board (REB) Final Approval
      If REB final approval copy is not available please provide REB # _____________(REB application copies are not required)
      If OCREB Approval has been granted, please include a copy of application & approval
      If Research Animal Ethics applicable, please include a copy of application & approval

      The budget is usually part of the agreement, please ensure it is included with the submission

    Account name:
                                                                 (maximum 30 characters)

    The account name must follow the Hamilton Health Sciences naming convention.
    The acronym must be followed by the Principal Investigator's (PI) or Most Responsible Person's (MRP) last name,
    then any study reference name can be added thereafter.
    The first character must be:
    N for New Investigator Fund awarded to conduct a research study, followed by the award number. Example: N09-123-Smith-X-Ray
    F for research study funded by Foundation (HHS or JCC). Example: F-Smith-X-Ray
    If the above does not apply:
    E along with the five digit research ethics board approved number. Example: E09-123-Smith-X-Ray
    D for a non-REB research study funded by a source other than the foundation and research development committee.
    Example: D-Smith-X-Ray
    O for a non-research related trust account (e.g. Sponsored education, forums, etc.). Example: O-Smith-X-Ray

    Principal investigator/
    Most Responsible Person:
                                         Name & Title                                                             Phone (include extension)

                                         Department                                                               Email

                                         Mailing Address

                                         Mailing Address

                                         Program Director

Revised 02 Nov 09                                                                                                                             1
    Account name:                                a8a48d10-0f96-443c-814d-f763b725631d.xls
                                                                 (maximum 30 characters)

    Individuals assigned signing authority by the PI/MRP are able to process deposits and payments against this account.
    The PI/MRP accepts personal financial liability for all expenditures on a study that exceed grants or supporting revenue.
    Please refer to Accountability Statement on page 3.

    Signing Authority 1:
                                        Name & Title                                                                 Phone

                                        Mailing Address                                                              Email

                                        Mailing Address

                                        Sample Signature (Required)

    Signing Authority 2:
                                        Name & Title                                                                 Phone

                                        Mailing Address                                                              Email

                                        Mailing Address

                                        Sample Signature (Required)

    Signing Authority 3:
                                        Name & Title                                                                 Phone

                                        Mailing Address                                                              Email

                                        Mailing Address

                                        Sample Signature (Required)

    Administrative Contact:
                                        Name & Title                                                                 Phone

                                        Mailing Address                                                              Email

                                        Mailing Address

    Purpose of this account:
                                        Clinical Trial(drug/device):     _____________________________

                                        Clinical Research: ________                   Clinical Trial Coordination:

                                        Pass Through:                                 Trust Account:

                                        Residual/O                                    Other:

    Funding Source:
                                        Include all funding sources if more than one.


    Project Location (%):

    Project Start:                                                                    Project End:

    Will there be salary expenses?                     Yes                    No      (circle one)
    (Salary expenses via HHS payroll)

    Do you have access to the
    GL Report Selector?                                Yes                    No      (circle one)

Revised 02 Nov 09                                                                                                               2
    Account name:                                    a8a48d10-0f96-443c-814d-f763b725631d.xls
                                                                    (maximum 30 characters)

                                                         Accountability Statement

    As Principal Investigator/Most Responsible Person for research or trust accounts established in my name, I acknowledge and
    accept my responsibility:

    1.      to read, understand and comply with all applicable sponsors’ policies, regulations, terms and conditions of award; 
            and all policies governing research/trust accounts, including, but not limited to, budget control, travel, ethics, and overhead;

    2.    to authorize all expenditures to be charged against my accounts or by a delegate(s) I have determined for this account;

    3.    to inform persons delegated signing authority on my accounts of applicable sponsor requirements (as outlined in 1. above)
          and of their associated responsibility for compliance;

    4.    to obtain any additional approval signatures, prior to making financial commitments;

    5.    to authorize and ensure delegate(s) authorize only allowable expenses against my account, which may involve
          consultation with the Office of Integrated Research Services and/or the sponsor;

    6.    to review monthly account statements to identify discrepancies and/or problems and to take corrective action in consultation
          with the Coordinator, Research Services;

    7.    to reimburse to the applicable account(s) any expenditures authorized by me or my delegates if disallowed by the sponsor;

    8.    to eliminate any unauthorized over-expenditures in accordance with the Banking Arrangements for Research & Investigator
          Liability Policy , which, if all other alternatives have been exhausted, requires personal responsibility;

    9.    to ensure all certifications are in order and comply with Hamilton Health Sciences, McMaster University and
          government and legal regulations covering the ethical and safe conduct of research.

    10.   to read, understand and comply with all Hamilton Health Sciences' policies and procedures and those of affiliated institutions
          where research or trust activities are being performed.

    11.   I understand I am responsible for the protection of data on my portable devices (i.e. laptops, USB and other) including the use
           of encryption and passwords to protect privacy and adherence to HHS Policy regarding responsible use - "ICT - Encryption Policy"

    I understand that the account opened may only be used for the original purpose intended.
    If a project ends, the account must be closed (however, a new account may be requested for a new purpose).

    I understand the funds administered by Hamilton Health Sciences are subject to audit by the institutions Chartered Accountants.
    As such, the Hospital reserves the right to review all reimbursements made directly to the principal investigator.

    Principal Investigator/Most Responsible Person (Print Name)

    Signature                                                                                            Date

    Internal Use Only:

    Research & Trust Department Authorization

    D. Simmons, CA                                                                                       Date
    Senior Financial Officer

Revised 02 Nov 09                                                                                                                              3

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