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Human Translational Core Sample Request Form
Please complete this form to obtain IBD and/or NAFLD samples. After submission, please send a notification email to:
sddrc@health.ucsd.edu
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* Indicates required question
Email
*
Your email
Center Member 1st Name & Last Name:
*
Your answer
Center Member Institution:
*
Your answer
Center Member Department:
*
Your answer
Center Member Phone Number:
*
Your answer
Center Member Email Address:
*
Your answer
Is the project funded?
*
Yes
No
Pending
If the project is funded, please provide the funding source.
Your answer
Is the project IRB approved?
*
Yes
No
Pending
Biospecimen request options:
*
IBD
NAFLD
Other:
Required
If Biospecimen "Other" option is selected, please specify.
Your answer
The number of patients needed for each disease type?
*
Your answer
Biospecimen options:
Serum (500 µl)
If serum sample is checked, please indicate the number of aliquots needed.
Your answer
Biospecimen options:
Plasma (500 µl)
Clear selection
If plasma sample is checked, please indicate how many aliquots you need.
Your answer
If whole blood is needed, please indicate the type of sample and number of tubes.
Your answer
If stool sample is needed, please indicate the desired volume.
Option 1
Clear selection
If precut slides are needed, please specify the number of slides needed.
Your answer
If tissue blocks are needed, please specify the number of blocks and anatomical location.
Your answer
If endoscopy biopsy samples are needed, please specify the anatomical location and number of samples needed.
Your answer
If liver biopsies are needed, please indicate the number of biopsies.
Your answer
If PBMCs needed, please indicate the desired number of cells.
Your answer
If "Other" biospecimens are needed, please specify.
Your answer
If any of the following services are needed, please specify
Clinical Consultation
Biostatistics Consultation
Pathological Consultation
Please provide a brief description of the proposed project and include specifications on diagnosis, active or inactive disease, etc…:
Your answer
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