Change in Pharmacy Contact Information Form

To submit this form, complete all required sections and sign it. Send a copy of the form along with your CV to your DAIT Project Manager via mail or email. For mail submissions, send to Division of Allergy, Immunology, and Transplantation, 5601 Fishers Lane, Room 7D30, Bethesda, MD 20892. For FedEx or UPS, use Rockville, MD 20852. For email submissions, locate the DAIT PM's email address in the study-specific manual of procedures. After submitting, file the original form in the pharmacy binder. My advice is to ensure that all contact information is clearly and accurately provided to avoid delays in communication.

Ensure to submit your Change in Contact Information Form as soon as any updates occur to maintain accurate records. Keep track of review periods and submission deadlines that may be specific to your organization or project requirements.

The purpose of this form is to notify the Project Manager (PM) of any changes in a pharmacy’s contact information. This includes updates to the pharmacy’s phone number, fax number, email, and physical/shipping addresses. By submitting this form, pharmacies can ensure that their information is kept up-to-date in the DAIT records, facilitating effective communication and operational efficiency.

• 1. Clinical Research Site Name: Name of the clinical research site.
• 2. Clinical Research Site Number: Unique identification number for the research site.
• 3. Pharmacist Name: Full name of the pharmacist.
• 4. Pharmacy Phone Number: Updated phone number of the pharmacy.
• 5. Pharmacy Fax Number: Updated fax number of the pharmacy.
• 6. Network/Consortium/Program/Grant: Information regarding the network, consortium, program, or grant-related to the pharmacy.
• 7. Pharmacy Address Changes: Sections to specify new mailing, shipping, and physical location addresses.
• 8. Signatures: Signature sections for the pharmacist, their supervisor, and acknowledgment from the PM or PS.
• 9. Date Fields: Dates when the form is signed.

Failure to submit this form can lead to outdated contact information. This may result in communication breakdowns and operational inefficiencies.

• Outdated Records: Failure to update the contact information means records will not reflect the current status.
• Communication Issues: Incorrect contact information can lead to communication failures between the pharmacy and the Project Manager.
• Operational Delays: Operational processes may be delayed due to the inability to contact the pharmacy promptly.

• 1. Change in Phone Number: Submit the form when the pharmacy's phone number is updated.
• 2. Change in Fax Number: Submit the form when the pharmacy's fax number is changed.
• 3. Change in Email Address: Use the form to notify the Project Manager of an updated pharmacist email address.
• 4. Change in Physical Address: Update the form when the physical or shipping address of the pharmacy changes.
• 5. New Pharmacist of Record: Notify if there is a new pharmacist of record or backup pharmacist.