Consultation Form
Therapeutic Validation Core
Room - R III C343, 980 W. Walnut Street
Nagendra K. Prasad, BVSc, PhD.
Director
nkprasad@iupui.edu
Tel: 317-278-6608  Fax: 317-274-8046
*Please provide all of the following information*
Principal Investigator Name:
PI Phone:
Co-PI (if any):
PI Address/Bldg:
Co-PI Phone:
PI Email:
Address/Bldg:
Cancer Center member:
 Yes
 No
Project Stage
 Exploratory
Email:
Preliminary/Pilot Study
Full Study
Funding Agency (If funded):
Expected start date of the study:
Disclosure Consent:
While we maintain strict confidentiality of patient information, we may on occasions need to disclose certain information of your
project in poster and oral presentations to our advisors and audience from Indiana CTSI institutions. Please indicate your consent
below for this type of disclosures by checking the appropriate box.
Type of information
1.
Your name/Department
2.
Your Project title
3.
Type of Assays (including rationale and objectives)
Yes
No
Project Description: Please include the objective of the correlative/pharmacodynamic assay(s), 1-2 line rationale for each, type
of sample and expected number of samples and patients in the proposed study.
Overall Goal:
Objectives:
Rationale (for each objective):
Study Details (number of patients, samples/patient, type of samples, and duration of the study as applicable):
TVC 06/01/2011