Intake Form 1

Intake Form 1

Screening questions asked for all projects

Submission Date*

Please select the date that this form was submitted

Submitter Name*

Please type the name of the person filling out this form

Submitter Contact*

Please list your email for us to contact

Investigator Name(s)*

Investigator Contact*

Please list an email for us to contact

Department*

Please select the department to which the investigator(s) belong. If the department is not listed, please select "other".

Select or enter value

If Other, Please Specify Department*

If the investigator's department was not listed, please provide it here.

Project/Protocol Name*

Brief description of your project/scientific protocol; including the target disease and candidate investigational product (therapeutic cell, genetic modification, viral vector, etc) (50 word max)

Investigator initiated or industry sponsored?*

Select

Company Name*

If your project is industry-sponsored, please provide the name of the sponsor.

Is this a preclinical, phase 1, 2, or 3 trial?*

Select

Please provide anticipated FDA submission date*

Does this project involve:*

Select

If other, please describe*

Support from LCGM*

Are you requesting support from Laboratory for Cell and Gene Medicine (LCGM) to support product development or manufacturing? If so, please select all that apply.

Select

Support from SCGT-CTP*

Are you requesting support from Stem Cell and Gene Therapy Clinical Trials Program (SCGT-CTP)? If so, please select all that apply

Select

Data Studies Support*

Are you requesting CTP support with conducting data-centered/chart review studies? If so, please select all that apply

Select

Grant Development and Support*

Select

Are you requesting CDCM inpatient beds?*

Select

Are you requesting Stem Cell unit clinical support*

Select

Attach key documents related to your project

(attach protocols, regulatory submission, publications below)

Key Document File Upload

Please attach a pdf file of your protocol synopsis or something similar. If there are no attachments with your submission, we will reach out for one before forwarding your intake 1 to our leadership committee for review/approval.

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