Biosamples for research request

Study title*

K-State IRB approval number*

PI name*

PI title*

PI department*

PI phone number

PI email address*

Funding/Sponsorship Information

Study Overview*

Primary Outcome Measure*

Sample request: clinical diagnosis/description*

Sample request: tissue details*

Sample request: total number of samples needed*

Sample request: requested starting date to receive tissue*

Sample request: information on preparation and preservation of samples*

Sample request: required sample information*

Projected start date

Expected duration (in years) of study from initial enrollment to completion of last subject

Anticipated total number of participants to be enrolled*

Are study procedures part of a regular medical visit?

Yes

No

Both

If YES, please provide:

If NO, please provide:

If the KSU-SV Research Center in the Stormont Vail Manhattan Campus is required, please provide:

Participant Description

Sex

All

Female

Male

Age limits

Inclusion Criteria

Exclusion Criteria

Please indicate if Stormont Vail participant recruitment services are requested

Yes

No

If YES, select the potential methods by which this study will identify possible participants

*If Other

Please indicate if Stormont Vail Medical Team services are requested

Yes

No

*If Other

Access to Electronic Health Records

Yes

No

If YES, have you previously used SV electronic health records for research?

Yes

No

Please indicate which portions of the Medical Record you will need to access to complete research

For what time period do you need access?

Biosample requests