AEHRP CQI initiation form

Award for Excellence in Human Research Protection
CQI initiation form

• Please use a separate form for each unique problem or suggestion: fax to 301-320-0978, page ____ of ____

• If desired, provide comparable information in a word processed document by fax or by email (to hii@hii.org)

• In description, if form pertains to a document, please reference (and/or attach) relevant pages, sections, etc (marked-up as appropriate).

Report of: Problem Suggestion Complaint Compliment Other, specify ____________

From: AAB member ASC member JCC member Judge Applicant Sponsor Staff
Other, specify _________________________________________________________________________

Name:__________________________________________________________________________________

Tel:____________________ Fax:____________________ Email:___________________________________

Are there attachments? Yes No

What is improvement priority? Critical Urgent Routine

Description of problem/complaint (no need to describe solution – we’ll investigate):
_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

Suggestion/improvement/compliment (whether or not intended to resolve above-described problem; we’ll evaluate suggested improvement’s feasibility):
_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

Comments:
_______________________________________________________________________________________

_______________________________________________________________________________________

Only for HII use:
HII classification: Assigned CQI ID: ______________

Processing log step	By	Date
Edited/Coded	_________	__________________
Entered	_________	__________________
QA’d	_________	__________________

version 1.2 – February 18, 2008

•	Please use a separate form for each unique problem or suggestion: fax to 301-320-0978, page ____ of ____
•	If desired, provide comparable information in a word processed document by fax or by email (to hii@hii.org)
•	In description, if form pertains to a document, please reference (and/or attach) relevant pages, sections, etc (marked-up as appropriate).