Dear Parent/Caregiver 5 April 2018 . United States Department of Education Office for Civil Rights CONSENT FORM - FOR REVEALING NAME AND PERSONAL INFORMATION TO OTHERS Participant Application Forms. Please read the acknowledgement of risk below and then confirm that you have read and understood the content of the document, agree to the booking terms and … The Duke University Research Support Services Agreement (RSSA) should be utilized to procure outside services on sponsored codes (20x-28x, A03, and 30x-38x). Completed form must be attached to an Accounts Payable Check Request when requesting payment or it must be attached to a Purchase Requisition when you are requesting a Purchase Order. Find out more. W-9 for Duke University Health System, Inc. 8233, Exemption From Withholding on Compensation for Personal Services of a Nonresident Alien Individual, Duke University Certificate of Foreign Status, https://resources.finance.duke.edu/resources/forms/Equipment_Screening_Form_2.19.pdf, Interdepartmental Request & Invoice Form (IRI), Laboratory Equipment Statement of Hazard Assessment, Sole Source Justification/Price Quote Selection Form, Departmental Accounts Payable Representatives, Business Processes and Forms Regarding Independent Contractors, United Parcel Service (UPS) Account Coding Instructions, Payments Other than Substantiated Expenses, Electronic Accounts Payable Check Requests, Corporate Card Suspension & Reinstatement, Corporate Card Mapping & Write-Off Schedule, Janitorial / Housekeeping Supplies & Services, Additional Terms for Vendors Providing Goods & Services to Duke Health, How to Provide Products or Services (DUHS), Online Tool Instructions (Clinical Engineering), PERT - Patient Care Supply Committee Overview. send completed form to: ROI-requestor3@dm.duke.edu; Fax: 919-620-5165 OR Duke University Hospital - HIM P.O. IRS Form W-9, Request For Taxpayer Identification and Certification is used by payers to properly report tax information from miscellaneous payments made to either, Duke University (for grants, contracts, interest, etc.) To be accompanied by Research Support Services Agreement (RSSA). The New Forest is a popular area for DofE expeditions for Bronze and Silver awards and organised walking groups. ). Consent to enrol from parent or guardian (if applicant is under 18 years old). Further resources are available from the Queensland Award Operating Authority. EOHW is not able to order a COVID-19 test for an employee until they sign this Authorization form. Permission numbers are used in the registration process to allow faculty to grant permission for students to enroll when the student does not meet a prerequisite, to override a class capacity, or when a class requires permission. This tracking number is essential if you need to inquire about your requisition. The Duke University Research Support Services Agreement (RSSA) should be utilized to procure outside services on sponsored codes (20x-28x, A03, and 30x-38x). This form is used to receive a valid Vendor Duke ID Badge. While it is not standard practice to waive the institutional insurance requirements, Corporate Risk Management may do so when circumstances dictate. Name Previous Award Unit. Download the Duke Health Enterprise Request for External Records Form (PDF, 952 KB) Download the Duke Health Enterprise General Authorization to DHE Providers' Access to Individual Electronic Medical Record (Maestro Care) (PDF, 766 KB) Download the Duke Health Enterprise Minor Patients (12-17 Years) Authorization to DHE Providers' Access to Individual Electronic Medical Record (Maestro Care) (PDF, 670.37 KB) Download the Duke … Mobile phone Date. I hereby authorize and consent to be treated by Duke City Primary Care, Inc physicians and staff. This form is used to determine if an individual performing services for the University qualifies (per the IRS) as an Independent Contractor or must be paid as a Duke employee. Ç7ww (zô�»ÿ>¾¼ûi‹nŞüşŸ»›ïŞı8†^ßß?¾xá¬n={cŞÈŞGkÑö£Õ-EÛ¢ z :::¾tt=èzĞõà׃®‡ü~Ğ{�. A “statement of research” is a required component of informed consent. • I consent to (insert participant’s name) _____’s participation in the above Adventurous Journey (AJ), including travel. The federal regulations at 45 CFR 46.117(b)(2) and 21 CFR 50.27(b)(2) permit the use of a short form consent document stating that the required elements of informed consent have been presented to the subject or the subject’s legally authorized representative orally, with a witness present. ). 1300 438 537. Learn More. DUKE OF EDINBURGH’S AWARD SCHOOL EXPEDITION BOOKING, MEDICAL & CONSENT FORM This form must be completed and returned to Reach Outdoors Ltd to book your place on a School Expedition. The Online Record Book (ORB) is an online system to help Participants, Award Leaders and Assessors doing, delivering and assessing the Award. Sign Up Donate Social Media. number of purposes, including, but not limited to, ensuring that the provision of, Duke Surgery provides a range of surgical services from routine surgery to the most complex procedures, including experimental and highly specialized treatments. Online record book help. Route Card: This is the form you record your map and compass details for your Adventurous Journey. Transform young people’s lives. Please check the following guidance as to the level of communication required. Revised 10/06/2006, 11/13/2007, 11/21/2007, 7/10/2013, 10/21/2013. or Duke University Health System (for medical services, interest, etc.). Introduce yourself and invite people to participate in your research. The Duke of Edinburgh’s Award Queensland State Award Operating Authority www.dukesaward.qld.gov.au P3 – Medical Consent Form PARTICIPANT CONSENT • I am sufficiently fit to participate in this program. Contact Us. Consent Form This service is being conducted by researchers at Duke University to provide more information to the general public on chemical applications in residential furniture. The first Duke of Edinburgh pratice walk has been scheduled for the Friday 11 May to Saturday 12 May 2018. You are being asked to participate in a research study. If conducting research with vulnerable populations and / or sensitive topics please Your child must have entered your email contact information in their ORB before you can submit your consent. IRI transactions show on financial reports with a "JV" reference. This document provides sample HIPAA language for the consent form and suggestions for where it may be added. Can eConsent be used on all projects? The Duke University Research Support Services Agreement (RSSA) should be utilized to procure outside services on sponsored codes (20x-28x, A03, and 30x-38x). You can also download our Participant App to access the Online Record Book anytime, anywhere. or Duke University Health System (for medical services, interest, etc. By continuing to use our website without changing the settings, you are agreeing to our use of cookies. The Sole Source Justification/Price Quote Selection Form should be utilized when an explanation as to the unique nature of the purchase of a good or service from a vendor on sponsored funds is necessary. The below forms are for Award Centres and adult volunteers. Initial: I confirm that I have correctly completed the online medical and registration form for my daughter/son/ward and have provided all … An OSA must be completed when engaging individuals or companies to perform certain outside services. Duke Health operations are We are using cookies to give you the best experience on our site. I understand that the outdoor nature of the AJ program will involve risks. A “statement of research” is a required component of informed consent. This Rider is required for Domestic RSSA (>$100,000) and International RSSA (>$100,000). It is where Participants can set up activities, record their efforts, upload evidence and submit assessor reports. Visit us on YouTube. As required by U.S. tax law and IRS regulations, Duke University and Duke University Health System have an obligation to determine if any payments made to a foreign vendor require tax reporting or withholding. P4 Adventurous Journey consent form (PDF, 131KB) or —keep the completed form in your personal files; learn about the Adventurous Journey requirements for participants. This form should also be submitted when submitting items to surplus valued up to $20,000. This form is required when submitting a Corporate Card Application. Use this version for international services costing greater than $100,000. I hereby authorize and consent to be treated by Duke City Primary Care, Inc physicians and staff. Flinders Island District High School student first to receive Bronze Duke of Ed Award this century on the Island. the current form consenting to the Minor (12-17) Duke MyChart Account. Patient Consent Form Box 90496 Durham, NC 27705 Phone: (919) 684-5600 Have questions? Once registered you can log in using the App. For hospitalized employees and in the event of the death of an employee or member of the employee's immediate family, the department designee should complete a Floral Request Form and contact the approved florist. If you filled in the registration form last year, most of the contact details should be filled out. Duke University Form 990 (current and past) Contact ORS: DUNS (Data Universal Numbering System) Number: 044387793: EIN (Federal Employer Identification/Tax Identification) Number: 56-0532129 or 1560532129A1 if prefix and suffix are required: End-User Certificates. IN THE NEWS February 23, 2021 Congratulations to Flinders Island District High School student Connor Wheatley who is the first on the Island this century … Read More >> You should assign a number for tracking purposes. Forms & Policies. This form may be used to Add the Accounts Payable Representative for your department. Once the consent form is submitted, the participant will receive an email that includes a PDF attachment with a copy of their signed consent form. I understand that the Award Centre will If you experience any technical problems with the Online Record Book, you can contact the National Award Operator: Online: Record book help Email: orb@dukeofed.com.au Phone: 1300 4 DUKES (1300 438 537) (select option 1) – Gold Notification Form – Scotland. Generally, a foreign vendor is subject to U.S. tax on its U.S. sourced income. This form will be shared with any supervisors, assessors that are involved in your expedition. Use this for to order banking supplies (deposit tickets, bank bags, etc.). However, if the revised consent form contains new information that may affect the subject’s willingness to continue (such as additional risks), the IRB may require re-consent as soon as approval of the continuing review is granted. The Duke Learning Management System (LMS) is used to deliver online training, manage classroom training and the associated learning transcripts for Duke Employees and its affiliates. PLEASE PRINT THIS FORM AND HAVE IT COMPLETED & SIGNED BY YOUR PARENT OR LEGAL GUARDIAN Please then return this signed document to your School Coordinator to confirm your place. For further clarification on how to use this form, please review the AP Check Request online video tutorial. The Purchase Requisition template you download will have a space for a tracking number. Frame Request Form: Purchase customized Duke of Edinburgh's Award frames, formatted to display your Bronze, Silver, or Gold Award certificates. The Duke of Edinburgh qualifying journey has been scheduled for 17,18and 19 May 2018. PARTICIPANT TRANSFER FORM. Use this version for international services costing between $10,001 to $100,000. This agreement should be utilized only when a determination is made that the entity is a vendor under the definition in OMB Circular A-133. Types of electronic requisitions are buy@duke for University and SoM/SoN departments and SAP e-reqs for DUHS departments. Completed form must be attached to an Accounts Payable Check Request when requesting payment for individual services, or it must be attached to a Purchase Requisition when you are requesting a Purchase Order. Handbook – The Duke of Edinburgh’s International Award Australia; Guide for Bronze Award Participants; Guide for Silver Award Participants; Guide for Gold Award Participants The form would be different in the case of focus groups or quantitative research. Home Mobile. This form is an easy to complete fillable PDF that documents the high level details of the Scope of Work, Invoicing Method, and Period of Performance with the given vendor. Introduce yourself and invite people to participate in your research. All product requests for trial or purchase must be approved by Duke Medicine's Product and Equipment Review Team (PERT) prior to bringing the product into the hospital. Sensitive Consent Forms A consent form that meets the definition of ‘sensitive’ should not be placed in the subject’s medical record unless it is determined to also be ‘clinically relevant’. Dear Parent/Caregiver 5 April 2018 . This form is used when you are requesting a copy of an accounts payable invoice. This form should be used to reinstate a card after suspension related to untimely postings. This form is used for the purchases of services. The Term Sheet for Purchased Services should be utilized when purchasing services on sponsored and non-sponsored funds which cost between $2,500 to $10,000. Please email qld.award.office@qed.qld.gov.au to request any of the below resources: P3 Adventurous Journey medical consent form. This agreement should be utilized only when a determination is made that the entity is a vendor under the definition in OMB Circular A-133. The Duke University Research Support Services Agreement (RSSA) should be utilized to procure outside services on sponsored codes (20x-28x, A03, and 30x-38x). Either use a separate consent form or ensure that the consent request is kept separate at the bottom of a form. This form is used for non-resident alien payments of other than substantiated expenses. We are asking you to complete your Authorization form now. The IRI form is used to order supplies or services from another department. I agree and I am over 18 years of age I am under 18 years of age but my parent or guardian has approved the consent . Laboratory equipment that needs an evaluation includes, but is not limited to the following: refrigerators, freezers, centrifuges, incubators, chemical fume hoods, biological safety cabinets and other items potentially contaminated with hazardous materials. This is accomplished through the development and implementation of policies and procedures that are intended to provide guidance for worker safety when handling biological agents. Participant’s Duke Unique ID Number (if a Duke Employee): Participant’s Social Security Number: - - If you do not want to provide your social security number, write your initials here _____. The form is used both as a request form and as a priced invoice. You should assign a number for tracking purposes. CONSENT - Please read carefully, initial the box and sign at the bottom to give your consent. 9. – Gold Notification Form – Cymraeg. Use only if the entity is foreign. Due to the wide variety of device configurations that access the LMS at Duke, it can be difficult to prevent all issues when launching e-learning courses and content from the LMS. Participant’s Duke Unique ID Number (if a Duke Employee): Participant’s Social Security Number: - - If you do not want to provide your social security number, write your initials here _____. I have been allowed to ask questions, and my questions have been answered to my satisfaction. – Gold Notification Form. Follow us on Instagram. To print: Click here or Select File and then Print from your browser's menu . Previous Award Leader / / Date of birth Email. The use of this form is expected to be on an exception basis and not a common occurrence. – Enrolment form for Leaders – Sample enrolment form for participants – eDofE data change request form – Gold Notification Form – Cymraeg – Gold Notification Form – Scotland – Gold Notification Form – Incident report form – EAAS Assessor application form – Variations application form Duke of Ed. Apply for The Duke of Ed. This agreement should be utilized only when a determination is made that the entity is a vendor under the definition in OMB Circular A-133. To sign in or register, click here. The group will be kayaking on a one way trip, down the Nepean River. Inform participants that you are a researcher from Duke University. Connect with us on Linkedin. You do not need to submit these to the Queensland Award Operating Authority. Once we receive your registration form and payment, we will send you a Participant Record Book, Expedition Guide and helpful hints and tips on completing your Award! Participant Application Forms. Package including Letter from Accounts Payable, Statement of Compliance, W-9, Vendor Information Form. You can still take part in the research study as described in the consent form document, but you will not be compensated for your participation. Frame Request Form: Purchase customized Duke of Edinburgh's Award frames, formatted to display your Bronze, Silver, or Gold Award certificates. Contact Us. EXCURSION INFORMATION AND CONSENT FORM . program for a Once the completed product request has been received, you will receive automatic notices as your request progresses through the PERT process. I consent to the Award Unit and any other individuals, including Volunteers#, who are involved in or assist in organising The Duke of Ed, and hired transportation drivers, transporting the Participant for the purpose of participating in activities or functions related to The Duke of Ed, as required. Skip to … My Global Ed: Duke Log-in Non-Duke Log-in. Consent to Participate in Research. I consent to transferring their Duke of Ed registration to New Award Leader. Registration form - This is the form you need to get started with the Programme. This form should be used to document Corporate Expenses when the original receipt has been lost. The screening form should be appear in the “Notes & Attachments” of the corresponding Buy@Duke cart. The Duke of Edinburgh's Award is the world's leading youth achievement award, with over 438,000 young people currently doing their DofE in the UK. Participant Application Form under 18 (parental consent required) Participant Application Form over 18 (no parental consent required) Guidelines. The submission is not complete until you consent to all 3 forms via an “Accept and Submit” button. This is a document internal to Duke University and should not be sent to an outside organization or vendor. Duke Health has implemented a compliance The number will be referenced in the description field. Duke Medical Supply, Inc. (Duke Medical) for any supplies furnished to me by Duke Medical. February 23, 2021. For more information call 13 13 02. Route Card: This is the form you record your map and compass details for your Adventurous Journey. This document provides sample HIPAA language for the consent form and suggestions for where it may be added. Supplementary forms. Fill out form on line and email to productrequest@duke.edu. You can download our Participant App to access the Online Record Book anytime, anywhere. This form should be used to reinstate a card after suspension. or Duke University Health System (for medical services, interest, etc. STATEMENT OF CONSENT "The purpose of this study, procedures to be followed, risks and benefits have been explained to me. By Paper - Using the Parent/guardian consent form, you will fill this out and submit … We request that all group organisers contact us to keep us informed of their planned visit to the New Forest. Details of this walk are available on … The Duke of Edinburgh’s International Award is a non-formal education and learning framework operating in more than 130 countries and territories around the world, through which young people’s achievements outside of academia are recognised and celebrated. Duke Human Resources 705 Broad St. A registration fee of $30 must be sent with the registration form. EXPEDITION CONSENT FORM. It is a contract between Duke and the contractor. Within DUHS use of a short form consent document is largely limited to two situations: They will catch a train to Suite 4, Level 3, 189 Kent Street, Sydney 2000, NSW; 1300 438 537; admin@dukeofed.com.au Some service areas have their own form so that they can get additional information needed (for example, Duke Publications Group). I agree to notify the AJS of any changes to my health and fitness, which may occur before, or during the AJ. Find an Award Centre: Check if your school or local youth organisation is an Award Centre. Suite 4, Level 3, 189 Kent Street, Sydney 2000, NSW. conducted in accordance with applicable laws and regulations. The group will be walking from Thornleigh Station to Circular Quay. Box 3016 Durham, NC 27710; For Questions Call: 919-684-1700 Upon submission of the current form, a third form for the Authorization of Text Communications will present and require submission. This form should be used for a individual requesting a Corporate Card. – eDofE data change request form. Find us on Facebook. An additional goal of this research is to collect more information on chemical applications in residential furniture over time and within different areas of the United States. Please complete this form no later than 1 week prior to your expedition. SUMMARY OF DETAILS First Name Last Name School Confirmation Number CONSENT - Please read carefully, initial the box and sign at the bottom to give your consent. All laboratory equipment must be free of hazardous materials (e.g. With the implementation of the Health Insurance Portability and Accountability Act (HIPAA), consent forms for all studies that accrue subjects within Duke University Health System must be modified for HIPAA compliance. IRS Form W-9, Request For Taxpayer Identification and Certification is used by payers to properly report tax information from miscellaneous payments made to either, Duke University (for grants, contracts, interest, etc.) Participant Consent Form This template is designed primarily for those doing qualitative interviews with adults from non-vulnerable populations and dealing with non–sensitive topics. Click Here for examples of the concise summary that must appear at the top of the consent form. Transactions that are more than 60 days old are not eligible for dispute. I consent to the Award Centre and any other individuals, including Volunteers#, who are involved in or assist in organising The Duke of Ed, and hired transportation drivers, transporting the Participant for the purpose of participating in activities or functions related to The Duke of Ed, as required. Please complete both sides thoroughly. These policies are based on the applicable regulatory requirements or current safety guidelines. Box 90496 Durham, NC 27705 Phone: (919) 684-5600 Have questions? and I consent to his/her participation in the above Duke of Ed Adventurous Journey. Participant Application Form under 18 (parental consent required) Participant Application Form over 18 (no parental consent required) Guidelines. The Adventurous Journey Supervisor (AJS) You are being contacted because, either you have never completed the EOHW COVID consent form, or you are currently due to renew your consent Authorization form. Before you agree to participate, it is important that you have received an oral explanation of this study in a language that is understandable to you. You will be notified by email with the necessary information. – Blue expedition form – overseas. Leader Registration Form. If this does not trigger the Parent/Guardian Consent email contact your Award Leader to re-send the Parent/Guardian Consent email via the ORB or complete the paper Participant Application Form – Under 18 and return it to your Award Leader. An electronic consent process (eConsent) is allowable on research studies, even for greater-than-minimal-risk studies. The paper Purchase Requisition should ONLY be used in rare occasions when an electronic requisitions are NOT appropriate (examples: leases, standing purchase orders for DUHS). Learn more about who we are and the impact we are making across Canada I agree to my son / daughter / ward doing a DofE programme. An equipment screening form is required when purchasing capital equipment on reportable awards. This document MUST NOT be altered. … An additional goal of this research is to collect more information on chemical applications in residential furniture over time and within different areas of the United States. Address Postcode. When preparing consent documents, you should: 1. Yes, enrollment can continue using the currently approved consent form (assuming it is not an expired consent form). It is required by the federal government to ensure they are not funding duplicative equipment. Follow us on Twitter. Use this version for domestic services costing greater than $100,000. Advanced Search. This resource contains the Office for Civil Rights Consent Form. Open to all backgrounds, cultures and abilities, a DofE Award can be a game-changer, raising young people’s aspirations and opening doors to employment whilst bringing together communities across the UK. Duke of Ed Participant Story Form. SUTTON GRAMMAR SCHOOL FOR BOYS - DUKE OF EDINBURGH SILVER CONSENT FORM This consent form covers the training sessions, practice and qualifying expeditions for Duke of Edinburgh Bronze. Signature Work phone. Students will begin their journey at Gosford Train Station. Donors may also request a Taxpayer Identification Number to enable them to claim tax deductions for gifts or donations. "toggle " + jQuery(this).prev().text() + " sub nav", Department Accounts Payable Representative Request Form, Corporate Card Reinstatement Request related to Untimely Postings, PDF - Department Corporate Card Setup Form, XLS - Dept Corporate Card Setup Form w/Instructions, Individual Corporate Cardholder Application, PDF - Individual Corporate Card Application, XLS - Corporate Card Application, Dept Setup Form w/Instructions for both, Statement of Corporate Card Disputed Items, WORKS (BOA) & Fleet Corporate Card Reinstatement, Checklist for Payment to Foreign Vendors (Entities and Individuals), Outside Services Agreement Insurance Exception Request Form, Research Support Services Agreement (Domestic): $10,001 to $100,000, Research Support Services Agreement (Domestic): > $100,000, Research Support Services Agreement (International): $10,001 to $100,000, Research Support Services Agreement (International): > $100,000, RSSA Rider A: Scope of Services, Deliverables & Payment Schedule, RSSA Rider B: Foreign Contract Additional Terms and Conditions, W-9 for Duke Regional Hospital (formerly Durham Regional Hospital), W-9 for Duke University Affiliated Physicians (DUAP).
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