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Lzh9UGeNPhYZbc27tyQD3qhwdF8sI5UxBpaTvL3sDseFKGYx4YCQqDbmGzXN5PkHPi2TCmVqItYhiXmZCNDLnk39U42fg9UjYx

Request for Indiana CTSI Clinical Research Services

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A A A

Please identify the Indiana CTSI Clinical Research Services you would like to utilize and provide the corresponding information requested.

Thank you!

Please check all Indiana CTSI Clinical Research Services that you are requesting [click on resource listed to learn more]:

CRC at IUPUI - University Hospital

CRC at IUPUI - Riley Hospital for Children

CRC at IUPUI - Goodman Hall

CRC at Purdue

CRC at IUSM-Evansville

ECG Interpretation

Please note:

The UH CRC Hours of Operation are:

Monday - Friday from 7A - 7P for outpatient visits, and
Tuesday, Wednesday and Thursday for overnight stays

If your study requires an outpatient visit or overnight stay outside of the CRC Hours of Operation, please contact the CRC Nurse Manager, Tina Nitsos, to discuss at tnitsos@iu.edu or 317-278-3567. CRC approval does not guarantee accommodation outside of the CRC Hours of Operation.

Please note:

The GH CRC Hours of Operation are:

Monday - Friday from 7:15A - 3:15P

If your study requires an outpatient visit outside of the CRC Hours of Operation, please contact the CRC Nurse Manager, Tina Nitsos, to discuss at tnitsos@iu.edu or 317-278-3567. CRC approval does not guarantee accommodation outside of the CRC Hours of Operation.

Your first name

* must provide value

Your last name

* must provide value

Your email address

* must provide value

Your phone number

* must provide value

Investigator First Name

* must provide value

Investigator Last Name

* must provide value

Investigator Degree(s)

PhD

DDS

DNS

PharmD

Investigator Email

* must provide value

Investigator Phone Number

* must provide value

Investigator Department / Division

* must provide value

Investigator Faculty Rank

Co-Investigator(s)

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What resource(s) is being requested the Children's CRC?

* must provide value

Participant Room

Phlebotomy

Nutrition

What resource (s) is being requested UH CRC?

* must provide value

Participant Room Only

Combination of visits requesting Participant Room Only and visits requiring Nursing Support

Nursing

Nutrition

What resource(s) is being requested for the Neuroscience CRC at Goodman Hall?

Participant Room Only

Combination of visits requesting Participant Room Only and visits requiring Nursing Support

Nursing

Nutrition

Will dry ice be needed?

Yes

reset

Will short term sample storage be needed?

Yes

reset

For what visits would you like the Phlebotomy Support at the CCRC [eg C1D1, V8, V1-V6, all visits]?

* must provide value

Expand

For what visits would you like the Participant Room Only resource at the UH CRC [eg C1D1, V8, V1-V6, all visits]?

* must provide value

Expand

For what visits would you like the Participant Room Only resource at the GH CRC [eg C1D1, V8, V1-V6, all visits]?

* must provide value

Expand

For what visits would you like Nursing Support at UH CRC [eg C1D1, V8, V1-V6, all visits]?

* must provide value

Expand

For what visits would you like Nursing Support at GH CRC [eg C1D1, V8, V1-V6, all visits]?

* must provide value

Expand

Please copy and paste the ECG information section from the protocol

* must provide value

Expand

Any other special instructions for interpreting ECG?

* must provide value

Expand

What resource(s) is being requested [Purdue]?

Nutrition Services

Plebotomy

Visit Space

Processing lab

Body Composition

Imaging

Other

What Administrative Assistance Service(s) is being requested [Purdue]?

IRB submission

Recruitment

Statistics

Web presence

What Nutrition Service(s) are being requested

Snack and/or FS tray

Dietary budget consultation

Research menu development

Meal preparation

Nutritional counseling

Dietary assessment services

Dietary homogenates

What Phlebotomy Service(s) is being requested [Purdue]?

Single stick

Multiple blood draws

What Visit Space is being requested [Purdue]?

Interview / Counseling

Bed

Chair

Meal Consumption

Other

If other, please specify

* must provide value

Expand

What Processing Lab Service(s) is being requested [Purdue]?

Initial processing

Short term storage

Send out samples

Repository of samples

What Body Composition Services are being requested [Purdue]?

Bod Pod

Metabolic cart

D.I. water

DXA

Skinfolds

Anthropometric measurements

Bioimpedance

What Imaging Services are being requested [Purdue]?

DXA

pQCT

MicroCT

What Other Services are being requested [Purdue]?

* must provide value

Expand

What is the project or protocol title?

Expand

Is this protocol:

* must provide value

Investigator-initiated

Industry-initiated

Investigator-initiated with Pharma support

reset

What is the funding source?

* must provide value

What is the funding source?

Please specify the NIH Agency

* must provide value

Please specify the Foundation

* must provide value

What is the Project Title [if different from the protocol title]?

What is the grant number?

* must provide value

Please specify the pharmaceutical company

* must provide value

If other, please specify

* must provide value

Is this a multi-center trial?

* must provide value

Yes

reset

Is this a clinical drug / device trial?

* must provide value

Yes

reset

What is the phase?

* must provide value

Is this phase I study the first in human?

* must provide value

Yes

reset

Is the I.U. Health Investigational Drug Service being used?

* must provide value

Yes

reset

Please upload the Protocol here

* must provide value

Upload file

Please upload the Investigator's Brochure here.

Upload file

Please upload the lab manual / lab instructions, if applicable.

Upload file

Please upload the DEXA manual, if provided.

Upload file

Please upload the "Signed Protocol Summary" document from KC-IRB. Please submit this form regardless of what IRB is being used (IU IRB or outside IRB - this form is still provided via Reliance request).

Upload file

Please upload the Main Informed Consent Document here.

* must provide value

Upload file

For pediatrics, please upload the Main Assent here.

Upload file

Please upload the Authorization Form here.

Upload file

Are there additional informed consent and/or assent documents associated with this protocol?

* must provide value

Yes

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Upload additional ICDs and/or Assent Documents here.

Upload file