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cBSR5Lkda6ZYoykBVwmVxhh7TeAvQG4uPnnoUkvWhZpWPw2jDjVvPC6y3gmxxV8jaFdBZN8WSprf6sC2RPFN9yIsza5s5

CRC Visit Request Form

Returning?

A A A

To schedule a study participant, please provide the required information below. Requests must be submitted by 12p the day before the visit.

Thank you!

What is your name?

If your name is not listed, please email Da'Ja Hill [ hilldaja@iu.edu ] and request to be added.

* must provide value

What is your phone or pager number?

* must provide value

Study Participant Demographic Information:

A 'Waiver of Authorization for Recruitment' is required when asking the participant to provide more than basic information prior to signing the informed consent / authorization. Therefore, some of the CRC-required PHI / Demographic Information cannot be asked without a "Waiver of Authorization for Recruitment".

If a 'Waiver of Authorization for Recruitment" has not been obtained, please provide as much information as possible when scheduling the screening visit. Once consent / authorization has been obtained, please provide the CRC outpatient receptionist or the unit secretary with the rest of the required information.

No further visits will be scheduled without complete information.

What is the participant's MRN or Study ID number?

* must provide value

What is the participant's first name?

* must provide value

What is the participant's last name?

* must provide value

What is the participant's Date of Birth?

* must provide value

M-D-Y

Is the participant male or female?

What ethnicity does the participant consider him/herself to be?

What race does the participant consider him/herself to be?

What is the CRC protocol number?

If the protocol number is not on this drop down list, please send an email to Da'Ja Hill (hilldaja@iu.edu)

* must provide value

What is the date of the visit?

* must provide value

M-D-Y

What is the start time of this visit (in military time)?

* must provide value

What is the end time of this visit (in military time)?

* must provide value

Is this a combined research / clinic visit?

* must provide value

Yes

reset

Please select all that you will need for this visit:

* must provide value

General Exam Room

Bed

Exam Room with table (RM 8 or 9)

Lab draw from CCRC staff

CTSL lab processing

What is the visit number (visit 8, cycle 1 day 1, Arm 1 or Cohort 3, etc) for this visit?

Expand

Lab Draw

Research only

Research and clinical

Special Instructions

Lab Draw: Special instructions

Expand

Please provide any other important information for this visit.

Expand

Are there more appointments you would like to schedule?

Yes

reset

What is the date of the visit?

M-D-Y

What is the start time of this visit (in military time)?

What is the end time of this visit (in military time)?

Is this a combined research / clinic visit?

Yes

reset

Please select all of what you will need for this visit:

General Exam Room

Bed

Exam Room with table (RM 8 or 9)

Lab draw from CCRC staff

CTSL lab processing

What is the visit number (visit 8, cycle 1 day 1, Arm 1 or Cohort 3, etc) for this visit?

Expand

Lab Draw

Research only

Research and clinical

Special instructions

Lab draw: Special instructions

Expand

Please provide any other important information for this visit.

Expand

Would you like to schedule another visit?

Yes

reset

What is the date of the visit?

M-D-Y

What is the start time of this visit (in military time)?

What is the end time of this visit (in military time)?

Is this a combined research / clinic visit?

Yes

reset

Please select all of what is needed for the visit:

General Exam Room

Bed

Exam Room with table (RM 8 or 9)

Lab draw from CCRC staff

CTSL lab processing

What is the visit number (visit 8, cycle 1 day 1, Arm 1 or Cohort 3, etc) for this visit?

Expand

Lab draw

Research only

Research and clinical

Special instructions

Lab draw: Special instructions

Expand

Please provide any other important information for this visit.

Expand

Would you like to schedule another visit?

Yes

reset

What is the date of the visit?

M-D-Y

What is the start time of this visit (in military time)?

What is the end time of this visit (in military time)?

Is this a combined research / clinic visit?

Yes

reset

Please select what is needed for this visit:

General Exam Room

Bed

Exam Room with table (RM 8 or 9)

Lab draw from CCRC staff

CTSL lab processing

What is the visit number (visit 8, cycle 1 day 1, Arm 1 or Cohort 3, etc) for this visit?

Expand

Lab draw

Research only

Research and clinical

Special instructions

Lab draw: Special Instructions

Expand

Please provide any other important information for this visit.

Expand

Would you like to schedule another visit?

Yes

reset

What is the date of the visit?

M-D-Y

What is the start time of this visit (in military time)?

What is the end time of this visit (in military time)?

Is this a combined research / clinic visit?

Yes

reset

Please select all of what is needed for this visit:

General Exam Room

Bed

Exam Room with table (RM 8 or 9)

Lab draw from CCRC staff

CTSL lab processing

What is the visit number (visit 8, cycle 1 day 1, etc) for this visit?

Expand

Lab draw

Research only

Research and clinical

Special instructions

Lab draw: Special instructions

Expand

Please provide any other important information for this visit.

Expand

Would you like to schedule another visit?

Yes

reset

What is the date of the visit?

M-D-Y

What is the start time of this visit (in military time)?

What is the end time of this visit (in military time)?

Is this a combined research / clinic visit?

Yes

reset

Please select what is needed for this visit:

General Exam Room

Bed

Exam Room with table (RM 8 or 9)

Lab draw from CCRC staff

CTSL lab processing

What is the visit number (visit 8, cycle 1 day 1, Arm 1 or Cohort 3, etc) for this visit?

Expand

Lab draw

Research only

Research and clinical

Special instructions

Lab draw: Special instructions

Expand

Please provide any other important information for this visit.

Expand

Would you like to schedule another visit?

Yes

reset

What is the date of the visit?

M-D-Y

What is the start time of this visit (in military time)?

What is the end time of this visit (in military time)?

Is this a combined research / clinic visit?

Yes

reset

Please select what is needed for this visit:

General Exam Room

Bed

Exam Room with table (RM 8 or 9)

Lab draw from CCRC staff

CTSL lab processing

What is the visit number (visit 8, cycle 1 day 1, Arm 1 or Cohort 3, etc) for this visit?

Expand

Lab draw

Research only

Research and clinical

Special instructions

Lab draw: Special instructions

Expand

Please provide any other important information for this visit.

Expand

Please click on the submit button to send the request to the CCRC.

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