Please complete this form and return to the Research Project Lead.

Please note that completion of this form does not constitute agreement to carry out this study.

Laboratory Research Number (LAB USE ONLY) / LR
Section 1 – Project Information
Principal Investigator: / Name:
Address:
Email:
Tel. no:
Study coordinator: / Name:
Address:
Email:
Tel. no:
Full study title:
Short title:
R&D number:
Ethics number:
Site(s):
Study start date:
Study end date:
Target recruitment for site: / IMP: / Comparator/Placebo:
Section 2 - Sponsorship and Funding
Sponsor name:
Funder name:
Commercial study – please tick: / YES NO
Eligibly funded/adopted study – please tick: / YES NO
Cost centre/grant code: (NA if commercial study)
Contact details for invoicing: (NA if commercial study) / Name:
Address:
Email:
Tel. no:
Confirmation funds available: / YES NO
Section 3 – Tissue Governance
Does the study involve tissue collection? / YES NO
Does the study involve tissue blocks from the diagnostic archive? / YES NO
Will any tissue be leaving Lothian? / YES NO
If the answer is YES to any question above please give details in Section 4 or use the NOTES space in section 5.

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Section 4 – Lab tests
Tests Required / Frequency
(days of week and approx. timings) – i.e. Mon to Fri – 2pm onwards etc / Number of tests per patient / Lab Dept / Cost/test
Research / Standard Care / Safety / Treatment / Lab use only
e.g. LFT / Mon-Fri 09:00 – 17:00 / 1 / 2 / 3 / 0 / Biochemistry / £2.04

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Section 5 – Terms and conditions
  • Any additional laboratory testing/ services required but not listed on this costing form must be costed and agreed separately.
  • Costs are only valid for 6 months from Laboratory sign off date. If the study begins outwith this period, the researcher must obtain revised costs.
  • If study exceeds a 3-year period, costs may be reassessed at the 3-year point at the discretion of the Research Project Lead.
  • Any amendment to the study protocol which affects the costs must be communicated to the Research Project Lead and new costs obtained.
  • It is the researcher’s responsibility to advise the Research Project Lead if patient numbers exceed that agreed on this form to allow reassessment of costs.
  • No laboratory tests will commence until all relevant approvals are in place.
  • It is the responsibility of the investigator/study coordinator to ensure that the correct lab tests are listed on the form.
  • It is the responsibility of the investigator/research nurses to ensure that the correct lab tests are set up in TRAK as an order set, if applicable.
NOTES
Section 6 - Approvals
Authorised by: / NAME / DATE
SIGNATURE

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