Crimson Core Request Form

Please fill in the following form to request services from the Crimson Core. Fields with an asterix (*) are required.

Section I: Contact Information for the investigator or project lead on the study, a primary contact (if different), and billing contact to receive invoices.
Field Investigator/Project Lead Primary Contact Billing Contact
Name: (*)
Institution: (*)
Address: (*)
City, State, Zip (*) , , ,
Email (*)
Phone (*)
FAX


Section II: Study and sample-specific information:
(*) Please indicate what services are needed.
    Samples for Research Clinical Trials Support CLIA Validation Set Other

(*) Protocol information: Do you have a Protocol (IRB, etc.)for the use of requested samples:
    Yes No In Process I don't know

    If "yes", please enter the following about your protocol:
Protocol type Granting Entity Protocol# Approval Date Expiration Date

Ex: Partners, DFCI, HMS COMS, etc

Format of MM/DD/YY

Format of MM/DD/YY

(*) Please describe the samples to be collected or submitted and how they will be used:

Additional processing/testing: Please indicate any additional processing or testing (check all that apply).
    DNA extraction RNA extraction
    Clinical Lab Testing (list tests):

(*) Sample Storage: Please indicate how samples should be stored until pickup or shipment (check all that may apply).
    -80*C -20*C 4* C ambient/room temp. other

(*) Storage Time:
    < month < year indefinite unknown

(*) Sample shipment or release: check all methods that may apply.
    Local pickup FedEx Other

(*) By when do you need or plan to begin:

Processing of Consented Samples
Please fill in the following fields if you are submitting samples from consented subjects.

    Total # of subjects to be consented for your study.
    Estimated # of sample submissions per month.

Check if you have a processing protocol from the sponsor.

Offhours/Weekend Processing: Indicate if you may need processing at the following times (check all that apply).
    8.30PM -> 8AM (3rd shift) Saturdays Sundays Holidays

Discarded Sample Collection
    Enter how many total discarded samples are needed.
    mL. Minimum volume per sample (e.g. 0.5mL, 2mL).

If you will be using a defined cohort for collection, please enter the source: