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Forms and general information

Find forms for researchers at VA Pittsburgh, categorized by type of research. Forms that apply to multiple types of research are listed under general research.

General research

Funding Source Codes (PDF)
Guidance on Written Agreements (PDF)
IBC Amendment Request Form (DOC)
Incoming Materials Transfer Agreement (MTA) Form (DOC)
Letter of Support from Service Lines Template (PDF)
Memorandum of Understanding (MOU) Template (XLSX)
Non-Financial Conflict of Interest Statement (DOC)
Non-VA Research Contribution Form (PDF)
Non-VAPHS Research Advertisement Request Form (PDF)
Notification of Publication/Presentation/Recognition of Research Results (PDF)
Outgoing Materials Transfer Agreement (MTA) Form (DOC)
Part I: Request to Conduct Research (PDF)
Privacy and Data Security Plan (DOC)
Request for Research Records Storage (DOC)
Research Financial Conflict of Interest Statement (PDF)
Research Office Building Conference Room Scheduling (PDF)
Research Scope of Practice (PDF)
Research Staff Form (DOCX)
Research Supply Request Form (PDF)
Research WOC Credentialing and Privileging Form (PDF)
University Administered Research Memo (DOC)
VA Form 10-5386/Investigator Data Sheet (page 18) (PDF)
VAPHS Administration of Extramural Grants Policy (PDF)
VAPHS Research Data Management and Access Plan (DMAP) Policy (PDF)
VAPHS Research Data Use Agreement (DOCX)
VAPHS Research DUA-DTA (PDF)
VAPHS Research Information Protection Program Policy (PDF)
VAPHS Research Written Agreement (DOCX)

Employment, training, and credentialing

Applicant's Statement of Service Registration Status (PDF)
Education Verification (DOC)
Form OF-306 (Declaration for Federal Employment) (PDF)
Form SF61 (Appointment Affidavits) (PDF)
Intellectual Property Agreement (PDF)
Policy Prohibiting Patient Abuse (PDF)

Research safety and security

Application to Access Research Secured Area (DOCX)
Request for Staff Access to Research Secured Area (DOCX)
Biosafety Level 2 (BSL-2) Procedure Template (DOC)
Chemical Matrix (XLS)
Hazardous/Select Agent Certification Form (DOCX)
Part II: Research Protocol Safety Survey (DOCX)
Part II Attachment A: Definition of Hazards (DOC)
Part II: Attachment B: Description of Biosafety Levels (BSL) (DOC)
Part II: Attachment C: Biological Safety Cabinets (DOC)
Part II: Attachment D: Listing of Common Controlled Substances (DOC)
Personal Protective Equipment (PPE) Hazard Assessment Certification Form (DOC)
Research Safety Incident Report Template (DOCX)

Committee forms

RSEC Research Project Closure Form (DOC)
Pre-submission and Administrative Review of Application for Research Funding (DOC)
Conflict of Interest Statement for Committee Members (PDF)

Animal research

Animal Budget Form (DOC)
Animal Exposure Preventive Medicine Program (AEPMP): Annual Review Form (DOCX)
Animal Exposure Preventive Medicine Program (AEPMP): Initial Exam Form (DOCX)
Animal Exposure Preventive Medicine Program (AEPMP): Declination Form (DOCX)
Animal Exposure Preventive Medicine Program (AEPMP): Vets/Non-affiliated Members of the IACUC (DOCX)
Animal Exposure Preventive Medicine Program (AEPMP): Non-Research Personnel  (DOCX)
Animal Protocol (ACORP) Amendment Request Form (DOC)
Animal Research Study Incident Report Template (DOCX)
Breeding Supplement (DOC)
IACUC Research Project Study Closure Form (DOCX)
Letter of Support IDS (DOCX)
Part IV: ACORP (PDF)
Protocol to Protocol Animal Transfer Form (DOC)

Human research

Find forms specific to human subjects research on ProSPECT.

Radiation safety

Application for Personal Radiation Monitoring Device (DOC)
Authorization to Purchase or Use Radiation Generating Equipment (DOC)
Form Letter for Declaration of Pregnancy (DOC)
Part V: Application to Use Radioactive Materials (DOC)
Radioactive Spill Report (DOC)
VAPHS Record for Radioactive Waste Disposal (DOC)

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