Request for CCS/CARS Services To request services at this time, please check all items of interest and complete the information below. Please send to Cheryl LaRue @ Box 1054 or fax signed document to 935-5862. Regulatory and Budget Services: IRB submission, follow up & other committees as required Study budget preparation/negotiation Assistance with pre-study site initiation activities Participant Recruitment Services: Recruitment Plan Development (no charge) Subject Pre-screening and Referrals Access to RPR database (no charge) (~10,000 volunteers) Advertising Development and Placement (no charge) Coordinator Services: Coordination of Protocol Procedures** Center for Advanced Medicine (CAM) Services: Medical Assistant Services Research exam room use*** Specimen Packaging and Shipping Specimen Storage (no charge) Study Drug Administration ECG Phlebotomy Other: Please specify __________________________ __________________________ __________________________ **If coordinator services are requested, we will evaluate the request based on feasibility first. ***Exam room use at CAM 11th floor research space will be charged at $15/hour for industry trials. Regulatory and Budget Services: Full time liaison between the Principal Investigator and the Institutional Review Board, as well as the Study Sponsor or the NIH. In addition, comprehensive budget preparation and consultation as needed between the PI and Study Sponsor. Please contact Phyllis Klein @ 747-4289. Participant Recruitment Services: Assistance with creating a comprehensive approach to maximizing recruitment efforts for a clinical trial (to include creative solutions to existing and potential recruitment challenges). Access to a volunteer database, in which potential participants can be queried by study inclusion and exclusion criteria, and pre screened for study fit. Also, any advertising assistance, whether by print or electronic media, can be utilized. Please contact Charles Rathmann @ 362-0897. Coordinator Services: Many of CCS’s research coordinators are RNs and ACRP certified. We provide study coordination from pre-site to close-out visit. The hourly rate is negotiable in accordance with your study budget. Please contact Teresa Arb @ 747-1217. Center for Advanced Medicine (CAM) Services: The research space is located on the 11th floor suite B. We have 5 fully equipped exam rooms in addition to 4 long-term areas for extended study visits. There are 2 areas for phlebotomy and lab processing complete with 2 monitored freezers, 1 secured medication refrigerator as well as centrifuges and standard lab supplies. We also have space for monitoring visits with wireless internet connection and we maintain a fully stocked crash cart. All staff is IATA certified and RNs are ACLS certified. Please contact Ann Doyle @ 286-1551. Name (required):_________________ Phone (required):________________ Pager: ___________________ Email: ___________________ Name of PI: ___________________ Box # of PI: ___________________ PI signature Study Sponsor:________________________________________ Name of Study_________________________________________ Protocol No ________________________________________ Protocol Status: Draft Final Study Start Date: ________________ Study Participants: Inpatient Target # of patients required date