Application for Research Services at the 1070 Arastradero Road Research Clinic
Clinical And Translational Research Unit (CTRU)
A core resource for Spectrum
(The Stanford Center for Clinical and Translational Education and Research)
PROTOCOL TITLE:
Principal Investigator:
Main Contact Person for Protocol:
Phone:
E-Mail:
STUDY CATEGORY:
Category A (NIH funded or non-profit funded; No industry sponsorship)
Category D (Industry sponsored)
Funding source:
Sponsor Name:
Grant number:
Does this funding include support for phlebotomy/laboratory assistance (Yes
IRB Approval Number:
/No
SPO Number:
REQUEST FOR CTRU SUPPORT:
Start Date:
Anticipated Stop Date:
Day Of Week Patients Will Be Seen (Check All That Apply):
AM: Monday
Tuesday
Wednesday
Thursday
Friday
PM: Monday
Tuesday
Wednesday
Thursday
Friday
Number Of Patients: Per Day
Per Week
Total For Study
Describe Procedures requested (phlebotomy, type of sample preparation, shipping, etc,):
INVESTIGATOR CHECKLIST:
Application completed and sent to CTRU Administrative Associate:
Copy of protocol and consent(s) sent to CTRU Administrative Associate
CTRU support staff contact information:
Michael Barany, Administrative Associate: mrbarany@stanford.edu, 725-9167
Ben Varasteh, Laboratory Manager: varasteh@stanford.edu, 723-7641
Renee Rittler, Administrative Manager: rittler@stanford.edu, 723-7496
Donna Adelman, 1070 Research Facility Manager: donna@stanford.edu 724-3121
NOTE: CTRU staff will request an account number for charge back of services provided.
)?