Briefly describe how this study is in line with the mission of Cardinal Hill Healthcare System (CHHS): to provide benchmark services in physical rehabilitation to our patients and customers?

What will the expectations of the CHHS be in this research project (i.e., financial costs, staff time, patient requirements, etc.)?

To aid us in the promotion of your research project, provide a brief (25-50 word) synopsis of your study in lay terms (e.g., This study examines the effects that walking on a treadmill, while being supported in a harness, has on leg muscle strength in patients who have had a spinal cord injury).

Please explain how participants’ protected health information (PHI) will be both protected from outside detection and destroyed upon completion of the study. (Attach additional sheets as needed.)

Please sign below to indicate that the participants’ PHI will not be re-used or disclosed except as required by law.

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Signature                                                         Date

Please return this form with your IRB approval form, Informed Consent form, and Research Proposal.  Thank You.