N.H. Admin. Code § Saf-C 5920.02

Current through Register No. 50, December 12, 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.