Clinical Services Core Facility Service Request Form


Completion of the following information permits the CWRU Center for AIDS research to charge the account listed upon fulfillment of requested services.

Request Date:

/

Account Number:

Principal Investigator(s): / Phone/Pager Number:
Project Support: /
NIH
/
Other
/
Unfunded
Project Title:
Institutional Review Board Approval Number and Expiration Date
/ I am requesting access to personally identifiable patient data(Copy of IRB-approved consent form required if not an investigator listed on the AIDS 125 protocol)
I am NOT requesting access to personally identifiable patient data
Brief Description of Project:

Project Approval (Grey areas below for CFAR office use only)

Core Director / Date / Priority assignment(a) / CFAR Clinical Core project number

(a)1 = NIH funded research at CWRU, CFAR investigator

2 = Non-NIH funded project at CWRU, CFAR investigator

3 = Funded project, non CFAR Investigator

4 = Other

Y/N / Signoff / Date
Database Request:
Patient Sample Request:
Repository Request:
Statistical request

CFAR Clinical Core project number:______Account Number:

Database Request

Describe Request

Computer time/Hours used ($40/half hour; $40 minimum): / Initials
Repository Request
(i.e. request to retrieve existing specimens stored in the repository)

Describe Request

Cryopreserved PBMCs @ $25 x _____ samples
Cell pellets @ $10 x _____ samples
Plasma @ $10 x _____ samples / For both repository and new patient specimen requests (below), please mark one:
Specimens will be used for genetic testing
Specimens will not be used for genetic testing
Total number of specimens provided: ______/

Initials ______

Clinical Research Core Facility Service Request Form

CFAR Clinical Core project number:______Account Number:

Patient Specimen Request
(i.e. request to obtain new specimens from SIU patients or other study volunteers)

Written consent is required with multiple blood draws or draws over 50cc. Attach a copy of IRB approval and consent form. Note: If patient sample coordinator is requested to get written consent, Investigator MUST provide protocol and rationale (Additional charge: $10/written consent).

Number of patients required:
Patient Consent Written: / Oral:
Patient Characteristics:
T-cell range:
Viral Load:
Other:
Sample type: / Blood: / CSF: / Stool: / Other-Specify:
Storage and handling of specimens: / Refrigerated: / *Other-Specify:
Tube type: / # of tubes**
Green top (heparin)
Red/Gray top, (serum)
Purple top, (EDTA)
Yellow top, (ACD)

** Approximate blood volume per tube = 8 cc

Other Instructions:
Total number of samples provided ($15/draw): / Initials:
Statistical Support Request
Type of support requested (check all that apply) / Study design
Sample size/power calculation
Randomization plan/management
Analytical plan design (e.g., for grant preparation)
Database design
Data storage and management
Table/figure preparation
Analysis of completed dataset

Describe Request in Detail

Total number of hours ______

/ Initials ______

By signing below, the requestor agrees to keep all patient names and identifiers (if provided) confidential.

Name / Date