CTSC APPLICATION FOR RESOURCE USE

The following information is needed so that the Clinical and Translational Science Center (CTSC) may assist Investigators with their research needs. WORK WILL NOT COMMENCE UNTIL THIS FORM IS APPROVED.

Please complete the following information:

  1. Funding Source: Grant Number (if applicable):
  2. IRB Protocol Number (if applicable): Approval date:
  3. Title of Study:
  4. Department/division financial manager:
  5. Department/division contact person:

Phone: Email:

  1. Grants manager (if applicable):

Principal Investigator and Personnel:

Employee Name & Degree(s) / NIH ERA Commons ID (for PI and Sub-I’s) / Study Role
PI

Short description of project: (attach a separate sheet if necessary)

Do you anticipate conducting part or all of the study in the CTSC Clinical Research Center (CCRC)? YES NO

How long will you need the services of the CTSC? Beginning Ending

Is this an investigator-initiated study? YES NO Is this a CTSC pilot project? YES NO

Please answer the following questions:

Which services will you need?

Clinical Research Coordinators: Contracts/budgetsRegulatoryStudy Coverage Monitoring ______

Approval

Nursing Support: At CCRC Inpatient UnitOutpatient Unit At location other than CCRC NP Services ______

Specify:______Approval

Dietary Assessment/Counseling: Computerized Food Record Analysis Specialized Diet Planning and Consultation

Metabolic Food Preparation______

Approval

Imaging - Radiology: X-ray CTMRI Ultrasound PET ______

Approval

Body Region to be imaged:

Body Composition Laboratory: DEXA (Bone Density, Total Body Fat)Bod Pod PQCT ______

Approval

Activity Monitoring Metabolic Testing (Rest, EE, Exercise) Body Impedance EKG Stress Testing Exercise Testing

Analytical Laboratory: Blood/tissue sample processingDNA sample processingRoutine chemistry/hematology

HPLC, GCMS, Flow Cytometry, Multiplexing______Approval

Biostatistics: YES NO______

Approval

Informatics: YES NO______

Approval

Database assistance:YES NO

Videotaping:YES NO

File Transfers:YES NO

Please provide a description of the services requested of the CTSC: (attach a separate sheet if necessary)

Human Subjects information (if applicable)

Does this study involve the inclusion of children? YES NO

Please provide the following information for all anticipated subjects:

The overall recruitment goals for this proposal:

ANTICIPATED TARGETED/PLANNED ENROLLMENT: Number of subjects
Ethnic category / Sex/gender
Females / Males / Total
Hispanic or Latino
Not Hispanic or Latino
Ethnic Category Total of All Subjects
Racial categories
American Indian/Alaska Native
Asian
Native Hawaiian or Other Pacific Islander
Black or African American
White
Racial Categories: Total of All Subjects

Justify the exclusion of Children, Women or Minorities (if applicable)

If this is a sponsor-initiated study, please provide the DaFIS account number associated with this trial.

Please include the following language for any papers you submit for publication if you have utilized any of the CTSC Services.

"This publication was made possible by Grant Number UL1 RR024146 from the NationalCenter for Research Resources (NCRR), a component of the National Institutes of Health (NIH), and NIH Roadmap for Medical Research."

Principal Investigator SignatureDate

CRRC ApprovalDate

Core Director ApprovalDate

Please email or deliver this completed and signed form to the UC Davis Clinical and TranslationalScienceCenter (CTSC), 2921 Stockton Blvd., Suite 1400, SacramentoCA95817 Attn: Debie Schilling along with the ICF, protocol and DOS if applicable.

Version date: 05/07/2007