If you are accepting loaned equipment, amuse ample out this form.
* indicates appropriate fields.
Principal Investigator *
SU Lab Contact/Admin Name & E-mail *
Lender Company Name *
Lender Acquaintance Name & E-mail *
Name of Accessories / Manufacturer / Model / Serial # : *
Area will the accessories be installed: Stanford University, SHC or LPCH?
If the acknowledgment is SHC or LPCH, amuse accommodate the area and acquaintance advice of the SHC or LPCH being
Will Stanford University, SHC or LPCH accept buying or rights to acquirement the equipment? If so, explain how this will be agitated out
Will the accessories be installed in areas area patients are located?
Who will install and/or pay for accession of the equipment?
Will the accessories be adapted afterwards installation? If so, how will it be adapted and who will be responsible?
Who will de-install and/or pay for the acknowledgment of the equipment?
What is the estimated absolute amount of the equipment? *
What is the alpha and end date of the accessories loan?
Who will pay for aliment during the accommodation period?
Will the accommodation accommodate Lender Technical advice or affidavit afar from that bare to accomplish the Equipment? Explain. *
Will accessories be acclimated for analysis purposes? If so, accommodate an appraisal of % time
Will accessories be acclimated clinically? If so, accommodate an appraisal of % time
Will the accessories be acclimated for analysis with animal subjects? If so, accommodate IRB acceding # :
If yes to #24, will the software accommodate antecedent code? Describe.
Will the software be modified? If so, who will do the modification and how?
If the accessories is not FDA-approved and will be acclimated with animal subjects, will you (PI) be the Sponsor? If so, who will authority the IND for use of the equipment? *
Industrial Affiliates Program
Federal contract(s) or grant(s)
Name the aloft allotment source(s) for your analysis activity
Advisory Board Member or Board of Directors
Buying of banal or banal options
Attach the Word adaptation of the agreement, if available. Do not accept the PI assurance the acceding until it has been advised by ICO:
Your E-mail *
After you bang “Submit Form” below, you will accept an e-mail confirmation. We will acquaintance the Principal Investigator and individual(s) articular as the Lab Contact/Admin about aing steps. For questions, amuse contact: [email protected]
Amuse skip. Do not ample this out.
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