SCTR Research Resources Support Request Form

To request research resources, please complete the form below. SCRC related requests should be submitted at least 2 weeks before you want to initiate your study. The SUCCESS and SCRC staff will contact you to provide further information and finalize your requests.

Principal Investigator
First Name: *
Principal Investigator
Last Name: *
Phone: *
Email: *
Research Coordinator
First Name:
Research Coordinator
Last Name:
Phone:
Email:
Project Funding Source:
Business Contact Person
First Name: *
Business Contact Person
Last Name: *
Phone: *
Email: *
Study Title: *
Study Initiation Date: (yyyy-mm-dd)
IRB/IACUC Number: (e.g. 11659, do not include the HR)
Inpatient Days Requested : (Per Patient)
Outpatient Visits Requested: (Per Patient)
Total Number of Patients Anticipated:

SUCCESS Center Services:

Consultation and Training for the Following Services (Check all that apply):

Regulatory Affairs
IRB Submissions
IND Process
Recruitment Services
Research Good Clinical Practice
Grant Submissions
Budget Development

General Clinical Research Center (GCRC):

Please Check the Services you are interested in (Check all that apply):

Exam Room
Nursing Services
Phlebotomy (Only)
Nutrional Services (Only)
Clinical Lab Services
Molecular Lab Services
Bone Densitometry (DEXA Scanning)
Electrocardiology
Biostatistical Consultation
Informatics Services
Body Composition
Dental Room
Infusion
Center for Cellular Therapy