19 - ITHS

advertisement
Date:
Study Title:
INSTITUTE OF TRANSLATIONAL HEALTH SCIENCES (ITHS)
UW CLINICAL RESEARCH CENTER (CRC) REQUEST FOR SERVICES
Instructions:
 Complete this registration if you wish to use the ITHS UW CRC and/or any
affiliated cores or resources.

If you have questions please email [email protected] or contact the CRC Program
Manager at (206) 598-4730.

Please email this completed registration form to [email protected] Make sure to
include these necessary elements:
o
Protocol (if you do not already have one, you may view a sample
basic protocol containing the minimal required elements for our
review)
o
Approved IRB application or Certificate of Approval (if available)
Thank you for providing this important information. We look forward to working with you!
1. Facility Utilization
1.1. Check ALL the Services You Wish to Use:
UWMC CRC Nursing (clinical unit for adult participants > 14 years of age)
Nutrition Services
Body Composition & Exercise Services
Gene & Cell Therapy Services/ Apheresis
Clinical Lab Facility
Drop-in Blood Draw
Consulting Room
Inpatient Research Activity Support
1.2 Tasks Desired (if applicable):
Frequent vital signs and/or height & weight
Frequent blood draws and/or PK draws
Lab processing of serum and/or urine test (i.e. biomarkers and/or PKs)
IV placement and/or IV medication infusion
Other: ______________________________
1.3 Anticipated Timeframe:
Start date:
___/___/_______
End date:
___/___/_______
1.4 Number of Study Participants To Be Enrolled: ________
ITHS UW CRC Registration form V6 05/26/2015
Page 1 of 2
2. Research Team
Primary Investigator:
Name (Last, First, Degrees)
Title
eRA Commons Username (if known)
School
Phone
Department or Division
Pager
Email
Mailbox
Co-Investigator(s) (if known)
Name (Last, First, Degrees):
ERA Commons User Name:
UW Net ID or Protect Net ID:
Key Personnel (Contact Person for all CRC-related matters)
Name (Last, First, Degrees)
Role in Research
(e.g. Research Nurse,
Study Coordinator)
Department or
Division
Phone
Email
Mailbox
Pager
3. Funding Source
Check your funding source
Federal (i.e. NIH)
Industry
Institutional/Departmental
Foundation
None of these
4. Study Information
Is this a clinical trial? (A 'clinical trial' is a research study in which one or more
human subjects are prospectively assigned to one or more interventions (which may
include placebo or other control) to evaluate the effects of those interventions on
health-related biomedical or behavioral outcomes.)
Yes
No
Is this study investigator initiated?
Yes
ITHS UW CRC Registration form V6 05/26/2015
No
Page 2 of 2
Download