1 Puerto Rico Clinical and Translational Research Consortium Genomic Translational Research Unit **Temporarily, this service will be offered according to the availability of our personnel** To request our services please complete the following information regarding your request for services/support to PRCTRC Genomic Translational Research Unit with the required documents and send it to: prctrc.rcm@upr.edu. If you have any question, please contact: Jessicca Renta-Torres, MS- jessicca.renta@upr.edu or 787-758-2525 ext. 1637 Carmen L. Cadilla-Vázquez, PhD- carmen.cadilla@upr.edu or 787-758-2525 ext.1372 Lilliam R. Villanueva-Alicea, MS- lilliam.villanueva@upr.edu or 787-758-2525 ext. 1633 I. Principal Investigator Information 1. Name (Last Name, First Name): 2. Degree: 3. Current Position: 4. Years in current position: 5. Institution: 6. School: 7. Department: 8. Program: 9. Section (if applicable): 10. Email: 11. Phone (XXX-XXX-XXXX): Degree Select Select your Academic Affiliation Select Select II. Request for Services Please specify which service(s) you want to receive: (**Please discuss this with the lab contact personnel [carmen.cadilla@upr.edu or jessicca.renta@upr.edu] before your selection(s)) DNA extraction and QC RNA extraction, cDNA template preparation, and QC Library Preparation for Sequencing, Templates preparation DNA Sequencing Reactions (type of service: whole genome, whole exome, transcriptome (RNAseq), ChIPSeq, other) Processing of raw data for subsequent bioinformatics analyses by investigator Other, please specify: Rev. 05.20.15 2 III. Samples Description Please provide information related to the samples that will be used through the Translational Genomic Research Unit. 12. Type of sample: 13. Type of organism: 14. Number of samples: 15. Number of runs per samples: PRCTRC Genomic Research Unit IV. Study Description Please indicate information regarding the study/protocol from the samples was collected: 16. Project Title: 17. Research Areas: Cardiovascular Cancer Other: HIV Neuroscience 18. IRB/IACUC Number: 19. IRB/IACUC Expiration Date: (mm/dd/yyyy) 20. Please provide a brief description of the study (< 250 words): **Include all that apply: (a) objective/specific aims of the study, (b) research plan, (c) methodology, and (d) findings, results or conclusions reached to date.** V. Study Funding Support Please provide information regarding the study/protocol funding support. Federal Sponsor Institution/Agency Name NIH **Specify grant Principal Investigator (PI) Other Non- Federal Industry Foundation/ Research Institute Funds Professional and Voluntary Association or Society Funds State, Country, City funds None Other Investigator Initiated Rev. 05.20.15 Grant # Please access the following link to verify the grant number and PI information http://projectreporter.nih.gov/reporter.cfm Total Budget (For funding period) 3 VI. Required Documents For the PRCTRC to support your research project, we will need the following documents to report on our outcomes and justify our budget to NIH. Thanks in advance! PI Biosketch (see Requesting Services from the PRCTRC-Biosketch form and example) Copy the IRB/IACUC Approval Letter Copy Biosafety Committee Approval PI Training Certifications (Human Subject Protection, HIPAA, IACUC, Biosafety/Biosecurity Training- if applicable) VII. Investigator Responsibilities 1 Progress report: We will request an annual progress report for each study. This information is part of NIH requirements to continue funding PRCTRC. 2 Data sharing: Data sharing is essential for expedited translation of research results into knowledge, product and procedures to improve human health. The National Institutes of Health (NIH) has a policy to share and make available to the public the results and accomplishments of the activities that it funds. 3 Acknowledgement of support: Each publication, press release or other document that results from NIH grant supported research must include an acknowledgment of NIH grant support and disclaimer such as: 4 The PRCTRC is committed in providing each study the best possible service. Due to a reduction in federal funding we may bill services for cost recovery. These funds will be used to continue supporting research projects. 3 The project described was supported by Award Number 2U54MD007587 from the National Institute on Minority Health and Health Disparities. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute on Minority Health and Health Disparities or the National Institutes of Health. I, , agree to fulfill the Investigator’s responsibilities and submit the information requested by Puerto Rico Clinical and Translational Research Consortium (PRCTRC). Rev. 05.20.15