Professional Documents
Culture Documents
*Do not include standard of care costs billable to the patient or his insurance company
Principal Investigator:______________________________________________________
Study Title:_______________________________________________________________
Sponsor:________________________________________________________________
Sponsor Protocol Number:_________________________________________________
RESEARCH SERVICES
I. PER PATIENT BUDGET
Study Time-Line Screening Visit Visit 1 Visit 2 Visit 3 Visit 4 Visit 5 Visit 6 Visit 7 Visit 8 Visit 9 Total
NUMBER OF PATIENTS 10
TOTAL PATIENT COSTS $ -
II. START UP COSTS INVOICED BY OCTA COST 33% IDC TOTAL OTHER FEES NOT INCLUDED IN THE PER PATIENT BUDGET
Institutional IRB Fee: $2000 (Non-Refundable) $ 2,000.00 NA 2,000.00 IV. Unit cost Frequency/ number 33% IDC Total Invoice
Protocol Review Fee (if applicable) - - Screening Failures 5 $ - $ -
Scientific Review Committee (if applicable) - - Optional CAT-Scan 1 $ - $ -
Non-Refundable Administrative Start Up Fee* (calculate using Time Other invoiceable patient clinical
& Effort Tab) - - procedures (insert rows as needed) 1 $ - $ -
Pharmacy Set Up & Storage (Obtain actual fees from NYPH Patient travel reimbursement (if not
Research Pharmacy) - - included in the per patient budget) 0 $ - $ -
Other: - - - Monitoring Visit 4 $ - $ -
The Office of Clinical Trials Administration will invoice the sponsor for the start up costs included in section II. The PI/Department is responsible for invoicing the sponsor for all other study activity according to the payment schedule negotiated in the clinical trial agreement.
NOTE: This budget template is blank. You may contact OCTA at OCTA@med.cornell.edu for a sample budget
This document is meant to aide in the process of conducting a clinical trial and its usage is not required, for it is not part of the formal procedure conducted at WCMC.