Weill Medical College of Cornell University
Clinical & Translational Science Center (CTSC)
CTSC Core Laboratory
Phone: Core Lab Director: (212)746-8348
Supervisor:
6-3480
Fax:
6-7698
Clinical & Translational Science Center (CTSC)
Core Laboratory Assay Request Form
(A separate copy of this submittal form is required to accompany each sample or time series.
For batches of identical assays, fill in one form and attach a list of samples)
Requestor: _________________________
Phone number: ____________________
E-mail address: _____________________
Department/Institution: __________________________________________
Principal Investigator: ______________________
IRB#: __________________ ____
(required)
Project Title:
Sample:
Submission date:
Sample ID #: __________________________
(Requestor’s reference number)*
[
] Male
/
[
Investigation date:
/
] Female
/
/
If time series, list all time points: ______________________________________________________________
Assays Requested:
# of
red-top, blue-top, etc) Tubes
Tube Type (e.g.
Volume/
tube (ml)
Sample Type
(e.g. blood, urine,
etc)
Assays Requested (e.g. total
testosterone, TNF, etc)
Special Procedures, if any
(sample preparation, extra
aliquots, etc)
Identify unusual biological hazards: _______________________________________________________
Received by ________________
Date ____/____/____
* Note: Privacy regulations require that the samples be identified by reference numbers (and investigator’s name)
only. The Core Lab cannot accept samples for assays labeled with the subjects’ names.