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Study Manager User Request Form

Instructions 1 - Complete this form. 2 - Click the "Confirm Request" button at the bottom of this page. 3 - Print the resulting confirmation page containing your responses. 4 - Obtain the appropriate signatures. 5 - Mail or fax approved completed request to: Barbara Covington, OCIS, BB8514, 1-8335 [Fax]. For more assistance contact Barbara Covington, x1-7581.

Department:	Department #:	Date:
Section:	Building Code:	Room #:
Section Supervisor:	Phone #:
School: Allied Health DentistryGraduate Studies Medicine Nursing

				Has user completed required CITI training?
User Name	Research Role	Email	Phone	Location	Yes	*No
		@mcg.edu
		@mcg.edu
		@mcg.edu
		@mcg.edu
		@mcg.edu
		@mcg.edu
		@mcg.edu
Department Authorization: Each section is responsible for the monthly user service fees invoiced by Study Manager (ACS). This agreement is for a one-year period (date of request) and will be renewed automatically unless otherwise notified. The amount due is based on the number of users and will be billed directly to the Section Supervisor (this can be paid by P-card). * If the required educational program (CITI) has not been completed, please contact Angela Randazzo at with your name, phone number, campus mailing address, and the type of research you are involved in.

June 06, 2007