The Mount SinaiPrecision Clinical Research Unit

The Mount Sinai

Precision Clinical Research Unit

Patient Recall Request

Principal Investigator

First and Last Name*

Email Address*

Phone Number

Protocol

Protocol Title*

IRB Protocol Number

Sponsor

Funding Type

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Specify other funding source

Is this request to generate preliminary data for a grant submission?

Yes

Upload a copy of the protocol here

You may also upload scripts, consent forms and other pertinent documents

Drag and drop files here or

Project Details

Patient identification method

Does the principal investigator have a cohort in mind or will the PCRU identify patients?

Pre-identified cohort

PCRU will identify

Specify allele of interest

Specify phenotype of interest, if applicable

Recruitment Start Date

Recruitment Target

Indicate the target number of patients to be recalled for this study

What recruitment materials will be provided?

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Type of Request

The PCRU can recall patients from BioMe/MSM and refer them to the requesting study team. The PCRU can alternatively enroll these patients under the PCRU protocol to undergo phenotyping. Phenotyping data, health information, and blood samples can be shared with the requesting study team.

PCRU Recalls and Refers

PCRU Recalls and Enrolls

Will participants be compensated?

Yes

Indicate compensation per visit (in USD) and expected number of visits

Describe your study team and its level of experience with patient consents

If you do not have a study team, please indicate here.

Requested Clinical Assessments

Indicate enrollment activities requested for the PCRU

Abdominal CT (non-contrast)

Anthropometric Assessment

Blood Sample Collection and Testing

Cardiac Testing

Carotid Ultrasound

Hearing Test

Neurocognitive Testing

Skin Biopsy

Smell Test

Urine Testing

Vision Testing

X-ray Fluoroscopy (bone lead)

Cardiac Assessments

Indicate individual assessments if known (optional)

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Neurocognitive Assessments

Indicate individual assessments if known (optional)

Select or enter value

Urine Tests

Indicate individual assessments if known (optional)

Select or enter value

Vision Assessments

Indicate individual assessments if known (optional)

Select or enter value

Additional information

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