DEPARTMENT OF LABORATORIES AND PATHOLOGY
LAC+USC HEALTHCARE NETWORK
Laboratory Agreement and Utilization Worksheet
Principal Investigator:
Email Address:
Billing Address:
Project Title:
IRB Proposal Number: HS -
Project Manager:
Email Address:
Telephone:
FAX:
Recruitment Locations:
Lab Agreement #
(to be assigned by Lab):
NAME OF TEST
NAME OF PERFORMING
LABORATORY
If this test is not performed by the
Clinical Laboratory at LAC+USC
Medical Center, please provide
address and phone number.
-
Pager:
Number of
Number of
times per
times per
patient the test
patient the
will be done for test will be
done for
ROUTINE
PATIENT
RESEARCH
CARE
TOTAL
NUMBER
of times per
patient the
test will be
done
NUMBER
OF
PATIENTS
Facilities where services will be needed:
LAC+USC Medical Center
H. Claude Hudson CHC
_____
_____
Roybal CHC
El Monte CHC
_____
_____
With my signature below, I attest this is an accurate listing of the types and number of laboratory tests that will
be performed for research and routine patient care during this study.
Type or Print Principal Investigator’s Name
Signature
Date
NOTE: 1. Billing will be managed by HSC-CRO (Steve Mackey @ 323-223-4091 x135 for details.
2. LACUSC Department of Pathology will not release the only diagnostic tissue block available and cannot
prepare slides for research studies. The USC Translational Pathology Core Facility at USC Norris Cancer
Center is available to prepare such slides for a fee, to be shouldered by the individual study.
IRB PROPOSAL #
Instructions for Completion of Laboratory Agreement and Utilization Worksheet
1. List all clinical laboratory services and tests that will be performed using blood, plasma, serum, urine, body fluids,
cultures, cells and tissues.
2. List the name of the laboratory that will be performing each test (LAC+USC Medical Center for tests performed at
the LAC+USC Medical Center County Clinical Laboratory). If a test will be performed by another laboratory, list
the name, address and phone number.
3. List the number of times per patient that each test will be performed for routine patient care. Routine patient care is
testing that would be performed (both type and frequency) if the patient were not participating in this research
protocol.
4. List the number of times per patient that the test will be performed for research. Research testing is testing (test type
or increased frequency) that would not be performed if the patient was not participating in this research protocol.
5. List the number of patients that will be accrued in the study.
PROCEDURE
1. The Laboratory Agreement/Utilization Worksheet request must be signed by the Principal Investigator or designee.
2. Before the Lab Agreement becomes valid, the IRB must have approved the study protocol, including the use of the
LAC+USC Clinical Laboratory for the requested testing of and/or services for the study participants in the protocol.
Please submit the Laboratory Agreement and Utilization Worksheet form to:
Mrs. Lourdes Rodriguez
Department of Pathology
LAC+USC Medical Center, Clinic Tower, Room A7E
Office Number: (323) 409-7154
FAX Number: (323) 441-8193
PRINCIPAL INVESTIGATOR or Designee:
Print
Signature
Date
LABORATORY AGREEMENT TO PROVIDE SERVICES
Faculty Liaison for Tissue Procurement
Date
Faculty Liaison for Clinical Laboratory Use
Date
Other Approval as necessary
Date
Laboratory Director
Date
REVISION DATE: 12/7/12