CTRU Request for Services

Date Submitted

mm/dd/yyyy

Project Subject/Title

Investigator Name

Phone/Email

College/Department

Anticipated Start Date

Number of Participants

Is this request for a future grant submission?

When is the grant submission deadline?

mm/dd/yyyy

Are all study services being provided by the CTRU?

Yes

Equipment Requested

Please select all that apply

DEXA

DEXA (non-CTRU operator)

DEXA (CTRU operator)

MRI

MRI (non-CTRU operator)

MRI (CTRU operator)

Metabolic Cart

Metabolic Cart (non-CTRU operator)

Metabolic Cart (CTRU operator)

Facilities Requested

Please select all that apply

Exam Room(s)

Laboratory (e.g., centrifuge, bench)

Phlebotomy Space

Other

Services Requested

Please select all that apply

Biospecimen collection and processing

Budget assistance

Data Collection

Data Management

IRB protocol assistance

Pharmacy and medication management

Physician oversight

Project Management

Nursing services (e.g., phlebotomy, IV)

Participant compensation

Recruitment Assistance

Recruitment material creation

Other

Account Number for Billing

Enter the internal account number for CTRU services to be charged

00000-00-000000-0000000

CTRU Fee Schedule Link

Study Details

Attach an overview of the study.

For studies requesting facility space, nursing, and/or data collection services please attach a current study design/protocol (i.e., flow chart of study visit steps) This is important for developing an accurate budget and evaluating feasibility.

Requests are evaluated for feasibility related to staffing and facility availability. Any questions regarding the study will be addressed with the researcher(s).

Drop your files here

Comments

CTRU Use Only:

Is this RFS submitted on behalf of the researcher?

Yes

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