UCLA Center for Pathology Research Services

UCLA Center for Pathology Research Services

Please submit this application to prior to beginning your research protocol. Please allow up to 2-3 weeksfor the processing and approval of this application. All studies requesting UCLA IDs must be registered in CareConnect. Studies not registered in CareConnect, will not be issued a requisition until registration has been completed.

Please note that research samples will not be accepted or processed until this application has been approved and a requisition is created.

STUDY INFORMATION
Protocol Name (less than 30 characters):
CTRC Protocol:
Protocol Summary:
IRB #: / IRB Approval Date:
Department: / Dept. Code:
Mailing Address: / Mail Code:
Principal Investigator: / Phone: / Email:
Research Coordinator: / Phone: / Email:
LAB RESULTS/REPORTS
How do you plan on identifying your subjects? Anonymous ID UCLA ID(CareConnect Registration Required)
If by anonymous ID, how would you like to receive lab results? Fax Network Printer (recommended)
If fax, please provide fax number(s):
If network printer, please provide printer model and printer IP address:
BILLING INFORMATION (required)
Grant & Fund Account # (FAU): / Recharge ID:
Billing Contact Person: / Phone: / Email:
Type of Research: NIH Funded Industry Funded Department Funded
TESTING INFORMATION
Study start date: Study end date:
Number of subjects needing lab tests:
Testing time points per subject:
If you indicated more than one time point, is the testing the same at each time point? Yes No*
If no, indicatein the table (page 2)which visit(s) each test is performed.
Sample types and volumes submitted for analysis:
Will these samples be sent individually (recommended) or in batches?
If batch samples, please detail:
SPECIMENS PROCESSING: IRB #:
Will you need the CTRL lab to process your specimens?
YES NO
Do you plan to have laboratory processing on the weekends?
YES NO
Will you provide the CTRL with all of the supplies?
YES NO
Will you provide the CTRL with detail processing instructions?
YES NO
NOTE:PLEASE PROVIDE DETAILED PROCESSING AND SHIPPING INSTRUCTION FOR THE LAB FOR THE DISCUSSION MEETING.
What type of processing?
CENTRIFUGE ONLY: PLASMA: SERUM: URINE: 
PBMC: * (P-39 form needed) OTHER (Complex Processing) : * (P-39 form needed)
Where will your study subject be seen?
UCLA RR: UCLA SMH: UCLA MED PLAZA:
If it is in another area besides the ones stated above, please indicate where:
Will you need CTRL lab to store your specimens? * (P-39 form needed)
YES NO
If yes, is it Ambient: Refrigerated (2-6 C): -80 C: 20 C:
NOTE: PLEASE SEE BELOW REGARDING CTRL’S ANNUAL FREEZER STORAGE PRICE
Do you want the CTRL to ship your specimens? * (P-39 form needed)
YES NO
NOTE:IF YOU WANT CTRL TO SHIP YOUR SPECIMENS, PLEASE PROVIDE CTRL WITH THE BOXES, AIRBILLS AND OTHER LABELS
ANNUAL STORAGE PRICING: *(P-39 form needed) SHIPPING PRICING:*(P-39 form needed)
* -20 C (2 mL vial box) $10.00 YES NO * Shipping Ambient (box < 1.5 cubic feet) $15.00 YES NO
* -20 C (4 mL vial box) $10.00 YES NO * Shipping Ambient (box > 1.5-3.0 cubic feet) $15.00 YES NO
*-80 C (2 mL vial box) $50.00 YES NO * Shipping Ambient (box > 3.0 cubic feet) $15.00 YES NO
* -80 C (4 mL vial box) $100.00 YES NO * Shipping Dry Ice (box <2 cubic feet) $15.00 YES NO
* Liquid nitrogen (2mL box)$140 YES NO * Shipping Dry Ice (box 2-4 cubic feet) $15.00 YES NO
* Shipping Dry Ice (box 4-8 cubic feet) $15.00 YES NO
* P-39 FORM NEEDED * Shipping Dry Ice (box 8-12 cubic feet) $15.00 YES NO
ADDITIONAL COMMENTS:
STUDY TEAM: (Set up appointment after approval)
DATE: TIME:
NAME: DATE: ___ /____ /____
NAME: DATE: ___ /____ /____
NAME: DATE: ___ /____ /____
NAME: DATE: ___ /____ /____
CTRL STAFF: (CTRL USE ONLY)
DATE: TIME:
NAME: DATE: ___ /____ /___
NAME: DATE: ___ /____ /___
NAME: DATE: ___ /____ /___
NAME: DATE: ___ /____ /___
TESTING REQUEST
You are required to provide the following information for your application to be processed.
Please also check the boxes below:
The above mentioned study has been registered in CareConnect
I acknowledge that the approval and requisition process may take up to 2-3 weeks
Please consult the on-line reference manual (Lexicomp) for test information:
Test Name / Test Code / CPT Code / Time Point for Testing / Research Price
CTRL Office Use Only

CTRL Form (9/2013)