Study Title:
INSTITUTE OF TRANSLATIONAL HEALTH SCIENCES (ITHS)
UW CLINICAL RESEARCH CENTER (CRC) REQUEST FOR SERVICES
Instructions:
· Complete this registration if you wish to use the ITHS UW CRC and/or any affiliated cores or resources.
· If you have questions please email or contact the CRC Program Manager at (206) 598-4730.
· Please email this completed registration form to . Make sure to include these necessary elements:
o Protocol (if you do not already have one, you may view a sample basic protocol containing the minimal required elements for our review)
o Approved IRB application or Certificate of Approval (if available)
Thank you for providing this important information. We look forward to working with you!
1. Facility Utilization
1.1. Check ALL the Services You Wish to Use:
UWMC CRC Nursing (clinical unit for adult participants 14 years of age)
Nutrition Services
Body Composition & Exercise Services
Gene & Cell Therapy Services/ Apheresis
Clinical Lab Facility
Drop-in Blood Draw
Consulting Room
Inpatient Research Activity Support
1.2 Tasks Desired (if applicable):
Frequent vital signs and/or height & weight
Frequent blood draws and/or PK draws
Lab processing of serum and/or urine test (i.e. biomarkers and/or PKs)
IV placement and/or IV medication infusion
Other: ______
1.3 Anticipated Timeframe:
Start date: ___/___/______
End date: ___/___/______
1.4 Number of Study Participants To Be Enrolled: ______
2. Research Team
Primary Investigator:
Name (Last, First, Degrees) / eRA Commons Username (if known)Title / School / Department or Division
Phone / Pager / Email / Mailbox
Co-Investigator(s) (if known)
Name (Last, First, Degrees):ERA Commons User Name:
UW Net ID or Protect Net ID:
Key Personnel (Contact Person for all CRC-related matters)
Name (Last, First, Degrees) / Role in Research(e.g. Research Nurse, Study Coordinator) / Department or Division
Phone / Pager / Email / Mailbox
3. Funding Source
Check your funding source
Federal (i.e. NIH) Industry
Institutional/Departmental Foundation
None of these
4. Study Information
Is this a clinical trial? (A 'clinical trial' is a research study in which one or more human subjects are prospectively assigned to one or more interventions (which may include placebo or other control) to evaluate the effects of those interventions on health-related biomedical or behavioral outcomes.)
ITHS UW CRC Registration form V6 05/26/2015 Page 1 of 2
Yes
No
ITHS UW CRC Registration form V6 05/26/2015 Page 1 of 2
Is this study investigator initiated?
ITHS UW CRC Registration form V6 05/26/2015 Page 1 of 2
Yes
No
ITHS UW CRC Registration form V6 05/26/2015 Page 1 of 2
ITHS UW CRC Registration form V6 05/26/2015 Page 1 of 2