1. (a) Each applicant for a protocol prerequisite approval shall complete a protocol prerequisite application which shall be:

   1. (1) Typewritten; or
   2. (2) Legibly printed.

2. (b) Each applicant shall provide the following:

   1. (1) Applicant information, which shall include:

      1. a. Legal name of unit;
      2. b. Mailing address;
      3. c. Physical address;
      4. d. City or town of residence;
      5. e. State;
      6. f. Zip code;
      7. g. Head of unit;
      8. h. Contact telephone number;
      9. i. Fax number, if available;
      10. j. E-mail address;
      11. k. Name of MRH;
      12. l. MRH medical director, or his or her designee; and
      13. m. Medical director contact phone number;

   2. (2) Type of application requested:

      1. a. Initial; or
      2. b. Renewal; and
   3. (3) The protocol title and number, for which the applicant is applying.
3. (c) The applicant shall submit supporting documentation for all elements listed in Saf-C 5920.01 (e) with a list of the licensed providers trained pursuant to Saf-C 5920.
4. (d) The form shall be signed and dated by the head of unit, as the applicant, and the MRH medical director, or designee.

Source. (See Revision Note #1 and Revision Note #2 at Chapter heading for Saf-C 5900) #12790, effective 5-24-19