CLINICAL PATHOLOGY RESEARCH SERVICES (CPRS) REQUEST FORM

The Department of Pathology is pleased to work with you on your new clinical trial/research project.

Obtaining Clinical Pathology Research Services (CPRS):

  1. Submit your completed CPRS Request Form to the CPRS Coordinator, via e-mail (preferred) or campus mail.
  2. Please include the complete protocol, specimen processing manual (if applicable) and an

IRB approval letter (if available).

  1. A CPRS Pricing Proposal will be sent to you via e-mail or fax.
  2. The Principal Investigator (or his designee) must sign and return the Pricing Proposal to the CPRS Coordinator.
  3. Customized laboratory requisitions will be generated for each research/clinical trial account. Specific registration, billing and testing information will be listed on the requisition.
  4. All research samples submitted to the clinical laboratory for testing and/or processing must be accompanied by a laboratory requisition.
  5. If the research protocol involves specialized specimen processing and shipping to a central laboratory, contact the CPRS coordinator to schedule the delivery of study materials, shipping boxes, air bills, etc. to the clinical laboratory prior to study initiation.
  6. Notify the CPRS Coordinator as soon as possible beforeaccrual begins for each protocol.

In summary, the CPRS requirescopies of the following documents for each clinical trial/research project:

a)Completed Clinical Pathology Research Services (CPRS) Request Form

b)Study Protocol

c)Specimen Processing/Lab Manual (if applicable)

d)Signed CPRS Pricing Proposal

e)IRB approval letter

For Questions/Submission of required documents contact:

Millicent Smith

Clinical Pathology Research Services (CPRS) Coordinator

P.O. Box 980258

Richmond, VA23298-0258

Phone: (804) 628-3996 Fax: (804) 827-1996

  1. Name of Department: Department Phone #

PO BOX: Department Fax #

  1. Principal Investigator In Charge of Study (First, Middle Initial, Last): Beeper # Phone #
  1. Study Contact or Coordinator: Phone # Beeper # E-mail address:
  1. Billing Information:

Same as above OR Name of Billing Coordinator:

Billing Address/ P.O. Box:

Phone # Fax#

  1. Start date: Duration of study: Number of patients expected (per year):
  1. Name of Funding Agency

Protocol #:

Type of Project: Pilot Study Research Clinical TrialOther:

Title of Study/Clinical Trial:

  1. Does this study involve processing and shipping of samples to a central lab? Yes No

Would you like to request that samples are processed and/or shipped by CPRS? Yes No

If yes, please indicate the services you would like performed by CPRS:

Specimen Processing

Specimen Storage (Room Temperature, Frozen, and/or Ambient > 24 hours)

Shipping to Central Laboratory (shipper boxes and airbills must be provided)

Other:

  1. Samples to arrive in lab: Weekdays Weekends Both

Samples to arrive in lab: Days EveningsNightsAll Shifts

Batched: Yes No

Are samples frozen? Yes No

Are samples from? Humans Animals (which species?)

  1. Will the study use the GCRC? (General Clinical ResearchCenter) Yes No

Will patients reside (i.e., >12 hours) in GCRC during study? Yes No

  1. Will the study involve any Blood Bank (Transfusion Medicine)? Yes No
  2. If yes, has their department been contacted? Yes No

Will the study involve any Anatomic Pathology services? Yes No

  1. If yes, has their department been contacted? Yes No

**If you are requesting Specimen Processing and/or Shipping Services only, STOP HERE. **

  1. How are results to be received?

Fax to dedicated fax number:

Mailed to PO BOX:

Cerner

Please provide full names of staff members that should have access to lab results for this trial:

  1. Who should be contacted with Panic Values? (24 Hours):

# 2 above

# 3 above

On Call Physician:Phone # Beeper #

Alternate Contact:Name Phone # Beeper #

  1. List laboratory tests required for the study: Please be as specific as possible (i.e., breakdown of Chemistry Panel etc.)

a. b. c.

d. e. f.

g. h. i.

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Date Rec’d: ______

Revised 11.09