Application for Laboratory Testing
UCLA CLINICAL & TRANSLATIONAL RESEARCH LABORATORY (CTRL)
10833 Le Conte Avenue, CHS A2-236
Los Angeles, CA 90095
Phone: 310-825-0825
Please submit this application to jtperry@mednet.ucla.edu prior to beginning your research protocol.
Allow 1-2 weeks for processing of application. You will receive email notification of approval and research pricing.
Please note that research samples will not be accepted or processed until this application has been approved.
STUDY INFORMATION
Protocol Name (less than 30 characters):
Protocol Summary:
IRB #:
IRB Approval Date:
Department:
Dept. Code:
Mailing Address:
Mail Code:
Principal Investigator:
Phone:
Email:
Research Coordinator:
Phone:
Email:
LAB RESULTS/REPORTS
How do you plan on identifying your subjects?
 Anonymous ID
If by anonymous ID, how would you like to receive lab results?
 UCLA ID
 Fax
 Network Printer (recommended)
If fax, please provide fax number(s):
If network printer, please provide printer model and printer IP address:
BILLING INFORMATION
Grant & Fund Account # (FAU):
Recharge ID:
Billing Contact Person:
Type of Research:
Phone:
 NIH Funded
Email:
 Industry Funded
 Department Funded
TESTING INFORMATION
Begin and end date of study:
Number of subjects needing lab tests:
Testing time points per subject:
If you indicated more than one time point, is the testing the same at each time point?
If no, indicate in the table which visit(s) each test is performed.
Sample types and volumes submitted for analysis:
Is there sample processing/storage associated with this study?
 Yes*
If yes, describe:
Do you require shipping of samples?
 Yes*
 No
If yes, describe and provide shipping information:
CTRL Form (Rev, 5/2012)
 No
 Yes
 No*
TESTING REQUEST
You are required to provide the following information for your application to be processed.
Please consult the on-line reference manual (Lexicomp) for test information: http://www.crlonline.com/lco/action/home.
Research Price
Test Name
Test Code
CPT Code
Time Point for Testing
CTRL Office Use Only
Principal Investigator’s Signature:
Date:
Approved by:
Date:
Anthony Butch, Ph.D.
Director, Clinical & Translational Research Laboratory
CTRL Form (Rev, 5/2012)