Principal Investigator
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Principal Investigator Email
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Principal Investigator Phone Number
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Study Nurse's Phone Number
Lead Coordinator/Contact for the Project
Coordinator's Primary Phone Number
Has your Research Project been approved by CHR or Western IRB?
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Yes
No
Please explain why this study is currently not approved:
Not submitted
Currently under review with CHR
Currently under review with Western IRB
Have you added the NCRU as a research program in your CHR application? (It is located under the "Sites" section of the CHR)
Yes
No
CHR or Western IRB Application
Download a PDF of your application onto your computer so that you can upload it and attach it to this application.
Today M-D-Y
Study Title
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Participant Category
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Research participants in investigator-initiated study
Research participants in industry-sponsored protocol
Research participants, protocol includes standard of care billable to insurance
Other
Please Note: The services performed at the NCRU cannot be billed to any insurance.
Is this study considered an FDA defined clinical trial?
Yes
No
Not Sure
Please identify the stage of your clinical trial
Phase I
Phase II
Phase III
Phase IV
Post Marketing
Please provide us with a brief protocol summary.
Yes
No
Please Contact Kristen Fox to discuss possible limited use.
This will be used by the NCRU for recharge purposes
This will be used by the NCRU for recharge purposes
If applicable
If applicable
Estimated Start Date at the NCRU
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Today M-D-Y
Do you have an end date, or a projected end date?
Yes
No
Today M-D-Y
Please explain if end date is not available:
How many total number of participants do you plan to enroll?
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How many visits per participant do you plan to conduct at the NCRU?
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For example: Each participant will have a total of 15 visits
What is the frequency of your visits?
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example: monthly or yearly
How many total number of visits do you plan to conduct at the NCRU?
* must provide value
Is there a required start time for any visits?
Yes
No
Now H:M
Does your study plan to use the NCRU outside of its regular business hours?
Yes
No
NCRU business hours are M-F 8am-5pm
On average, how long are the visits?
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30 minutes
1 hour
1-2 hours
2-4 hours
5 hours
6 hours
All Day
On average, how many study visits per week do you plan to have at the NCRU?
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On average, how many study visits per month do you plan to have at the NCRU?
* must provide value
Ambient Temperature
-4C
Other
4C
-20C
-70C
-80C
Sample Processing Services
please check all that apply
Unless sample collection tubes will be immediately transferred to another laboratory outside of the NCRU after the visit, sample processing should be checked.
Please upload appropriate certification for study personnel.
If available, please upload your study's Lab Manual
Please upload appropriate certification.
What Type of Room(s) will your study require?
please check all that apply
How long will your study utilize the exam room?
30 minutes
1 hour
2 hours
3 hours
4 hours
Other
How long will your study utilize the consult/interview room?
30 minutes
1 hour
2 hours
3 hours
4 hours
Other
How long will your study utilize the infusion room?
30 minutes
1 hour
2 hours
3 hours
4 hours
Other
How long will your study utilize the patient group room?
30 minutes
1 hour
2 hours
3 hours
4 hours
Other
Does your study require any of the following procedures or procedure rooms?
please check all that apply
Are there any safety concerns with your study population that we should know about?
Please check all that apply
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