N.H. Admin. Code § Saf-C 5920.02

Current through Register No. 44, October 31, 2024

Section Saf-C 5920.02 - Protocol Prerequisite Application Form

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

(1) Typewritten; or

(2) Legibly printed.

(b) Each applicant shall provide the following:

(1) Applicant information, which shall include:

a. Legal name of unit;

b. Mailing address;

c. Physical address;

d. City or town of residence;

e. State;

f. Zip code;

g. Head of unit;

h. Contact telephone number;

i. Fax number, if available;

j. E-mail address;

k. Name of MRH;

l. MRH medical director, or his or her designee; and

m. Medical director contact phone number;

(2) Type of application requested:

a. Initial; or

b. Renewal; and

(3) The protocol title and number, for which the applicant is applying.

(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.

(d) The form shall be signed and dated by the head of unit, as the applicant, and the MRH medical director, or designee.

N.H. Admin. Code § Saf-C 5920.02

(See Revision Note at chapter heading for Saf-C 5900) #7690, eff 5-21-02, EXPIRED: 5-21-10

Source. #9779-A, eff 9-8-10

Amended by Volume XXXIX Number 24, Filed June 13, 2019, Proposed by #12790, Effective 5/24/2019, Expires 5/24/2029.