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CLC Service Request Form
Briefly tell us a little about your project and needs. We look forward to meeting with you to discuss further.
Please contact christine_goodwin@brown.edu with any questions.
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Email
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Your email
Investigator Name
Your answer
Department
Your answer
Contact Name
Your answer
Contact Email Address
Your answer
Desired Start Date
MM
/
DD
/
YYYY
Do you have IRB approval for the work requested?
Yes
No
In progress
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Do you have Biosafety Committee approval for the work requested?
Yes
No
Not applicable
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Clinical Support Services Requested (check all that apply)
Physical exams
Clinical administration of sensitive questionnaires
Clinical monitoring during medication administration
Assessment and follow up of suicidality and adverse events
Phlebotomy
IV start/blood draw from IV catheters
N/A
Other:
Blood Processing Services Requested (check all that apply)
Blood sample centrifugation
Pipetting
Labeling
Preparation for storage
N/A
Other:
Laboratory Analysis Support Requested (check all that apply)
Biological sample processing and storage
Analysis of inflammatory biomarkers on-site using the Ella Multiplex System
Preparation and shipment of biological samples for analysis at other laboratories
N/A
Other:
Research Support
Setting up contracts with laboratories and other research support entities
IRB and IBC protocol development and submission assistance
Training on human subjects research data collection procedures
Assessment, sourcing, provision of supplies
N/A
Other:
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