Investigational Drug Services (IDS) Intake Request Form

Investigational Drug Services (IDS) Intake Request Form

UCSF Health IDS provides services for the following:

Study start-up time from a pharmacy perspective is typically 3 months.

All areas covered under the General Acute Care Hospital License (GAC-H). This includes PARN, BCH, MZ, PCMB, Weill, Bayfront, and Pritzker Building (specific areas). This form will be used for satellite/regional sites including BOPC and CCSM (soon to be POPC). For ZSFG and other non-UCSH sites, please contact that IDS department directly.

Inquiry is related to the following (select one)*

Select

Preferred email contact for questions related to submission*

Email of individual submitting the form or point of contact for study (study team represenative)

Lead IDS Pharmacist*

If unknown, select "other"

Select

IRB*

Put TBD if not determined yet

CC Number

Protocol Sponsor Number/Nickname

Ex: Internal nickname, Sponsor protocol number, etc

Principal Investigator*

Type of Study*

Who is sponsoring the study? Funding source?

Select

Project Manager

Budget Analyst

File Upload - attach documents (protocol, pharmacy manual, IB, NTF, etc)

Drag and drop files here or

Where are the pharmacy services needed, where will patient be seen/receive drug?

PCMB will support all regional site (POPC, BOPC, CCSM). If the site is not listed here, please reach out to the contact at the specific site directly.

Select

Estimated SIV Date*

Estimated First Patient*

General Information: any additional notes or information (not available in other fields)

Examples: all-inclusive budgets, only opening specific arms, etc.

Send me a copy of my responses

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