Weill Medical College of Cornell University
Clinical & Translational Science Center (CTSC)
CTSC Core Laboratory
Phone: Core Lab Director: (212)746-8348
Supervisor:
6-8910
Fax:
6-8352
Clinical & Translational Science Center (CTSC)
Core Laboratory Assay Request Form - 2016
(A separate copy of this submittal form is required to accompany each sample or time series.
For batches of identical assays, fill in one form and attach a list of samples)
Requestor: ____________________
Phone number: ________________
E-mail address: ___________
Department/Institution: ______________
Principal Investigator: ______________
IRB#: ______________ EPAR#____________
(required)
Project Title: ______________________________________________________________________
PI shall report unusual biological hazards:___________________________________
Sample Collection Date/(Time):
/
/
(___:___)
Initials: ___________________
Sample ID #: __________________________
(Requestor’s reference number)*
Assays Requested:
# of
red-top, blue-top, etc) Tubes
Tube Type (e.g.
Volume/ Sample Type
(e.g. blood, urine,
tube (ml)
etc)
Assays Requested (e.g. total
testosterone, TNF, etc)
Special Procedures, if any
(sample preparation, extra
aliquots, etc)
* Note: Privacy regulations require that the samples be identified by reference numbers (and investigator’s name) only.
The Core Lab cannot accept samples for assays labeled with the subjects’ names. All assays are for research purpose only.
___________________________________Lab
Sample Date/(Time) Received By Lab Staff:
/
Use Only______________________________________
/
(___:___) Initials: ____________
Conditions Samples Arrived (Check One): Frozen: ___ Semi-Frozen: ___ Room Temperature Liquid: ___
Identify insufficient sample volume: _________________________________________