Stipend Card Request Form

Initial Amendment
Department/Center conducting research:
Research Site: Research Site:
Address Line 1 Address Line 2 City State / Province / Region Postal / Zip Code Country
Study Name (short name):
Study Status:

Study Status: Start-Up Enrolling Active Long-term Follow Up Close-Out
Study ID (protocol number):
Study Budget (estimated number of subjects x stipend amounts):
Estimated Subject Enrollment:
Study Role:

Study Role: Medical Student Psychology Student Non-COM OSU-CHS Employee (please list position) OSU-CHS Employee (please list position)
Study Description or Long Title:
Maximum of 1500 characters allowed. Currently Entered: 0 characters.
Sponsor:
PI:
Stipend Card Funding Approver:
Fund Number:
Primary Research Coordinator Contact Info:
Maximum of 1500 characters allowed. Currently Entered: 0 characters.
Is the stipend for travel or meal reimbursement?

Is the stipend for travel or meal reimbursement? Yes No
If yes, what are the terms?
Maximum of 1500 characters allowed. Currently Entered: 0 characters.
Total Number of Visits and Naming Convention:
(if stipend amount varies per visit please list total sum after each visit name below)
Maximum of 1500 characters allowed. Currently Entered: 0 characters.
Associated Stipend Amount per visit:
IRB of Record:

IRB of Record: OSU Advarra Sterling WCG Veterans Affairs IRB Other Other
IRB Approval Number:
IRB Approved Consent Form:

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