CTRC Consult Request

Please complete the following worksheet form, and attach your protocol document. If you receive an error message when submitting (i.e you forgot to complete a required area), you MUST reattach your protocol before resubmitting the consult request.

NOTE: This is only a consult request. Once you are ready to submit a formal application for review, you must follow the process outlined in the CTRC Protocol Application Process page.

Investigators receiving ICTR Clinical and Translational Research Core (CTRC) services agree to cite UW-ICTR by stating in the acknowledgment section of your publications the following message: Supported by grant 1UL1RR025011 from the Clinical and Translational Science Award (CTSA) program of the National Center for Research Resources, National Institutes of Health.

Fields marked with an asterisk are required.

PI Information

Protocol Attachment:

* You must attach your protocol document/draft in either Word (doc) or pdf (pdf) format.

Principal Investigator (PI) Name: *

(Last name, first name).

Brief Protocol Title:

Sponsor Study Number (if assigned):

Please reference in any communications

Proposed funding source: *

NIH

Foundation

Private

Industry

Department

State/Local Govt

Not Funded

Other

Other funding source:

Point of contact name for questions: *

Contact's telephone number: * Please enter phone in the format xxx-yyy-zzzz

Extension:

Contact's Pager Number:

Contact's Email address: *

Is the principal investigator an ICTR member: *

Yes, the PI is an ICTR member

No, but he/she will complete the membership application today. (http://www.uwictr.wisc.edu?q=ictrmember)

CTRC Usage

Estimated # of CTRC Study Subjects: *

Diagnosis: *

description or ICD9 code(s) or normal volunteer(V70.7)

CTRC Inpatient Description

Inpatient:

(study visits that are expected to be >=10 hours in length need to be submitted as inpatient admissions)

Number of Admissions per Subject:

Number of nights per admission:

List Days (e.g., Days 1-2, Days 15-16, etc.):

CTRC Outpatient Description

Outpatient:

(study visits that are expected to be >=10 hours in length need to be submitted as inpatient admissions)

Number of Visits per Subject:

List Visits( e.g., Day1, Visit 4 etc.):

CTRC Room Usage

Will any visits be Room Usage Only?:

Yes

No

(no CTRC nursing or lab staff involvement, your study personnel will perform all study procedures).

If Yes, list Room Usage Only Visits:

Resources Needed from CTRC

Identify the services that you are requesting be done BY CTRC STAFF (check all that apply):

NURSING (RN):

Anthropometric Measurements

ECGs on hospital equipment

ECGs on sponsor-provided machine

Nitric Oxide

Physical Assessment

Questionnaires

Sample Acquisition

Sample Processing (provide specific processing instructions)

Koko Spirometry

Jaeger Spirometry

Other

If Other, Please list:

NURSE PRACTITIONER (charges will apply):

Exams (PE)

Other

If Other, Please list:

RESEARCH BIONUTRITIONIST (charges may apply):

Dietary assessment (food records, Food Frequency Questionnaire, etc.)

Nutrition Education

Research meals

Other

If Other, Please list:

Identify the services YOUR STAFF will perform:

Anthropometric Measurements

ECGs (on sponsor-provided machine)

Exams (PE)

Physical/Activity Assessment

Questionnaires

Sample Acquisition

Sample Processing

Spirometry

Other

If other, please list:

Indicate equipment/materials that you are requesting (check all that apply):

Centrifuge

Freezer -20°C

Freezer -70°C

Metabolic Chamber

Oximetry

Polysomnography

Koko Spirometry

Jaeger Spirometry

NIOX

Scales for drug weighing

Special tubing, filter, blinding for study drug (should be discussed with Pharmaceutical Research Center)

Special tubes (i.e., not provided by UWHC) for sample processing

Storage of sponsor-provided ECG machine

Telemetry

Other

If other, please list:

Indicate who will complete processing of lab specimens (regulations prohibit CTRC from shipping):

CTRC

UWHC

Other Lab

If other Lab, please identify:

Consultation Action

What type of consultation are you requesting?: *

No response needed

Response via email

CTRC to contact you to set up a meeting

Consultation Questions (list):

CAPTCHA

This question is for testing whether you are a human visitor and to prevent automated spam submissions.

Math Question: * 4 + 4 =

Solve this simple math problem and enter the result. E.g. for 1+3, enter 4.