The code block below illustrates how one might use # and // as comments in your logic and calculations.

# Text can be put here to explain what the logic/calculation does and why.
if ([field1] = '1' and [field2] > 7,

	// This comment can explain what the next line does.
	[score] * [factor],

	// Return '0' if the condition is False.
	0
)

Working …

This value you provided is not a number. Please try again.

This value you provided is not an integer. Please try again.

The value entered is not a valid Vanderbilt Medical Record Number (i.e. 4- to 9-digit number, excluding leading zeros). Please try again.

The value you provided must be within the suggested range

The value you provided is outside the suggested range

This value is admissible, but you may wish to double check it.

The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).

This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.

This field must be a 10 digit U.S. phone number (like 415 555 1212). Please re-enter it now.

This field must be a valid email address (like joe@user.com). Please re-enter it now.

The value you provided could not be validated because it does not follow the expected format. Please try again.

Required format:

Advarra Participant Payments Project Request Form

Study Title

* must provide value

Study Short Title

* must provide value

PI Full Name

* must provide value

Project Contact

* must provide value

Project Contact Email

* must provide value

Department / Division

* must provide value

Please specify the other department.

* must provide value

Click IRB Number

Is this study in OnCore?

Yes No

reset

OnCore Protocol Number

Non-OnCore Protocol Number

OnCore Protocol Title

OnCore Protocol Short Title

NCT#

Study Status

Not yet open to accrual

Open to accrual

Closed to accrual

reset

Account Number

* must provide value

Account Number End Date

M-D-Y

Company

* must provide value

Please specify the company.

The following roles are available through Advarra Participant Payments:

• Participant Check‐In and Pay - this role can add participants, assign them to protocols assigned to the user, check participants in for visits, and send payments for participants for financial review.
• Financial Reviewer - this role can review and pay stipends and reimbursements for their assigned protocols. This role can run reports for protocols assigned to the user.

Shazam SC Role

SC1 Name

SC1 Department

SC1 Email

SC2 Name

SC2 Department

SC2 Email

SC3 Name

SC3 Department

SC3 Email

SC4 Name

SC4 Department

SC4 Email

SC5 Name

SC5 Department

SC5 Email

SC6 Name

SC6 Department

SC6 Email

SC7 Name

SC7 Department

SC7 Email

SC8 Name

SC8 Department

SC8 Email

SC9 Name

SC9 Department

SC9 Email

SC10 Name

SC10 Department

SC10 Email

SC11 Name

SC11 Department

SC11 Email

SC12 Name

SC12 Department

SC12 Email

Shazam FR Role

FR1 Name

FR1 Department

FR1 Email

FR2 Name

FR2 Department

FR2 Email

FR3 Name

FR3 Department

FR3 Email

FR4 Name

FR4 Department

FR4 Email

How many cards would you need to start?

Estimated number of cards over study lifetime?

In words, please provide a description of any approved stipends or reimbursements for your study.

Expand

Please provide a copy of the Informed Consent Form (ICF) or other document which describes the stipends and/or reimbursements that will be provided to participants.

* must provide value

Upload file

If you have more than 8 study visits for your study, please make sure you upload a simple outline of the Study Visits, Stipend Amounts, and Reimbursements for your study.

Upload file

Are you Paying Reimbursements?
(i.e. Hotel, Mileage, Parking, Other)?

* must provide value

Yes No

reset

Shazam SV

Visit Name

Stipend Amount

Reimbursement

Hotel Mileage Parking Other

Visit Name

Stipend Amount

Reimbursement

Hotel Mileage Parking Other

Visit Name

Stipend Amount

Reimbursement

Hotel Mileage Parking Other

Visit Name

Stipend Amount

Reimbursement

Hotel Mileage Parking Other

Visit Name

Stipend Amount

Reimbursement

Hotel Mileage Parking Other

Visit Name

Stipend Amount

Reimbursement

Hotel Mileage Parking Other

Visit Name

Stipend Amount

Reimbursement

Hotel Mileage Parking Other

Visit Name

Stipend Amount

Reimbursement

Hotel Mileage Parking Other

Shazam USV

Visit Name

Stipend Amount

Reimbursement

Hotel Mileage Parking Other

Visit Name

Stipend Amount

Reimbursement

Hotel Mileage Parking Other

Visit Name

Stipend Amount

Reimbursement

Hotel Mileage Parking Other

Visit Name

Stipend Amount

Reimbursement

Hotel Mileage Parking Other

Reimbursement Rules

The Reimbursement Rules section only appears when you indicate reimbursements are allowed in the protocol. Here, you set the parameters for distributing reimbursements to participants.

In the following example, the following Reimbursement Rules applies

Guidelines - enter a note such as indicating which parking lot is eligible for reimbursement
Maximum Hotel Reimbursement - $100
Maximum Parking Reimbursement - $20
Mileage Rate per Mile - $0.50
Travel - reimburse participants that travel at least 20 miles but no more than 40 miles

The following Reimbursements Rules would apply for this study

Reimbursement Guidelines	Parking Lot A only available for this study
Maximum Hotel Reimbursement	$100
Maximum Parking Reimbursement	$20
Mileage Rate per mile	$0.50
Minimum miles for Reimbursement	20
Maximum miles for Reimbursement	40

Please provide the Reimbursement Rules for your study

Reimbursement Guidelines

Maximum Hotel Reimbursement

Maximum Parking Reimbursement

Mileage Rate per Mile

Minimum Miles for Reimbursement

Maximum Miles for Reimbursement

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