UWHIS Data, Specimens, and Referral Services

Investigators requesting specimens or referral services, please contact Jordan G. Graff, CFAR Translational Research Subcore manager, who will assist you in completing this form. (206-744-4630 - jggraff@uw.edu)

Investigators requesting clinical data may contact the UWHIS Research Assistant, Matthew Jackson, for assistance. (206-685-7791 - mkj5@uw.edu)

Please allow two weeks for fulfillment of each submission; for requests needed in a shorter amount of time, the Data Manager, Peggie Griffith, may be contacted to discuss expedited service. (206-744-3683 - peggieg@uw.edu)

Study Investigator Information

If you are filling this form out on someone else's behalf, please use their information, not your own.

Study Investigator Name

NIH Reporting

Please provide the following information required by CFAR for NIH reporting.

Study Investigator Professional Status

Study Investigator NIH Funding Status

NIH HIV/AIDS PI (investigator who has ever been the PI on an R01 equivalent grant in HIV/AIDS)

NIH PI newly beginning HIV/AIDS research (investigator who has been the PI on an R01 equivalent grant but not in HIV/AIDS)

NIH New Investigator who has received funding as a PI from NIH, but not yet at the R01 equivalent level (New Investigators include K Awardees; this term is fully defined on the NIHs website)

Investigators who have not received funding from NIH as PI or Co-PI on any NIH grant mechanism

Additional NIH Reporting

Member of an Underrepresented Group in Research (defined as: African Americans, Hispanics, American Indians, Alaska natives, native Hawaiians, Pacific Islanders)

Woman

None of the above

Contact Information

Research Center/Lab Group

Mailing Address

Phone

Request Type

Please select one of the following...

Feasibility (to determine whether there are enough subjects or specimens meeting your study criteria and/or to apply for a grant to fund your study; you will receive aggregate data, does not require Human Subjects approval)

Clinical data set (to request data for subjects meeting your study criteria)

HIV Specimen Repository (to request specimens and associated clinical data already collected and stored in the repository)

HIV Research Study Screening and Referral Nurse Service (to identify and recruit potential research subjects for your study)

Grant Application Source

NIH or Other

This request is not for a grant application

NIH Institute

Grant Application Title

Application Number

Is the PI of the grant application the same person as the study investigator?

Yes

Study Information and Data Request

Study Title

Specific Aims

Inclusion Criteria

Exclusion Criteria

Study Time Frame

Prospective recruitment of subjects/collection of specimens

Clinical data/stored specimens

Specimen Information

Please provide additional details regarding the specimens you are requesting.

Collection Procedures

(Please specify procedures you would like the CFAR assistant to perform or assist with)

Signature

Name

Date

mm/dd/yyyy

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