1. There Are Two Ways to Request CRSSC Services

1.  There are two ways to request CRSSC services:

a.  Complete this CRSSC request form as a stand alone application and submit to: OR

b.  Complete as an appendix of the ITHS CRCN Services Supplement through the IRB-ITHS application process as Appendix 7. https://www.iths.org/sites/www.iths.org/files/forms/CRCN/Appendix7_ITHSCRSSCServiceRequestForm.doc

2.  Assignments are determined by the Research Supervisor of the CRSSC. Core personnel resources are dependent upon staff availability.

3.  If request is approved, this form serves as the agreement between the investigator and CRSSC for services and time commitment.

Form Completed By: / Date:
1. Study Team
Principal Investigator: / Position: Faculty Staff Post-doc/Fellow
Department/Division: / PI Email:
Primary Study Team Contact: / Phone: / Email:
Title: Assistant Associate Professor Other
Additional study team members:
Center Affiliation: Child Health, Behavior and DevelopmentChildhood Infections and Prematurity ResearchClinical and Translational ResearchDevelopmental TherapeuticsImmunity and ImmunotherapiesNeuroscienceTissue and Cell Sciences
Center Business Manager or Grant/Contract Administrator:
2. Project Information
Project Title
Concise Summary or Abstract
(Less than 300 words; outline purpose, rationale, study design
Type of Funding / Public Private, non-profit Corporate/ Industry Unfunded Other
Study Type / Retrospective Observational Small Prospective Observational Large Prospective Observational Drug Trial Non-Drug Trial QA/QI Other
Requested Services / Prepare and submit IRB-ITHS documents
Regulatory support
Electronic Data Capture/ Database design (e.g. REDCap)
Assist with study sponsor visits
Coordinate research activities with hospital services
Recruit and schedule participant visits
Facilitate participant visits
Consent/assent participants
Administer surveys/questionnaires
Simple data collection/chart abstraction
Complex, clinical data collection/chart abstraction
Data entry
Nursing activities (e.g. blood draw, IV placement, specimen collection, participant education, adverse event assessment and reporting, pain scores, chart abstraction requiring clinical judgement)
Behavioral intervention
Other, please describe
IRB #: Pending N/A / IRB Approval Dates to
Study Code: RS_ N/A / Initial IRB Approval Date:
Activity/Budget #:
Duration of CRSSC Support (Dates): to / Hours per Week:
Hours of Support*: Business Hours Early AM Evenings Nights Weekends On-Call

*Core staff are available Monday through Friday, during regular business hours. Extended and weekend hours may be available upon availability and approval.

CRSSC Application 06/13/2013 Page 1 of 2