CORE Research Application

Step 1 of 12 - Principal Investigator

Principal Investigator

Principal Investigator Name*

First Last

Position/Title*

Institution*

Phone Number*

Alternate Phone Number

Email Address*

Website URL:

Is the primary contact information the same as the Primary Investigator?*

Yes

Primary Contact Name*

First Last

Primary Contact Position/Title*

Primary Contact Institution*

Primary Contact Phone Number*

Primary Contact Alternate Phone Number

Primary Contact Email Address*

Project Information

Project Title*

Purpose of Project/Research*

Describe Research Project*

Please use plain English, as we will use this information when approaching families for obtaining consent for your study

Desired Start Date*

MM slash DD slash YYYY

Do you currently have funding for this project?*

Yes

Source of Funding*

Do you have IRB Approval?*

Yes

N/A

How would you describe your organization?*

Is this a "For Profit" Organization*

Yes

Are you conducting this research as part of a grant or are you in the process of applying for a grant?*

Yes

Would you consider including CORE as a collaborator on this grant project?*

Yes

N/A

Biospecimen Information

Biospecimen*

If approved, will continue to add to this to match placement sheets, and ideally LLTN

Other Biospecimen*

Tissue Size*

Whole

Partial

Number of Samples Requested Per Donor*

Number of Samples Requested throughout duration of Study*

Frequency of receiving specimens*

Daily

Weekly

Monthly

Other

Other frequency of receiving specimens*

Will this biospecimen be recovered by CORE?*

Yes

Recovery By*

Please indicate your availability for days below:

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Donor Criteria

Min Age*

Please enter a number from 0 to 150.

Max Age*

Please enter a number from 1 to 150.

Sex*

Female

Male

Both

Race*

American Indian/Alaska Native

Asian

Black or African American

Native Hawaiian

White

Any

Donor Type*

Brain Death

DCD

Tissue

Inclusion (list any other criteria)

Serologies: Are any of these UNACCEPTABLE

HIV

HBV

HCV

RPR

Toxoplasma

Additional Requests

Please Indicate whether the proposed research project involves any of the following:

Donor Data

Yes

Medical Device

Yes

Study of a Drug

Yes

Testing for Genetic Diseases or genetic Markers

Yes

Please indicate the Information you will need post acceptance:

Donor Chart

Yes

Recovery Details

Yes

DRAI

Yes

Serologies

Yes

Organ Specific Testing

Yes

Lab Results

Yes

Additional Comments

Allocation Information

How would you prefer to receive offers? (Select all that apply)*

Phone Call

Text

E-System

Access to DonorNet

Do you need full redacted chart at time of referral?*

Yes

Availability: Can you receive offers 24/7?*

Yes

Please indicate your availability for days below:

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Will this study be seeking research organs and/or tissue from other organizations?*

Yes

Name of Organization*

Recovery Information

Methodology for Procurement*

Attach SOP if available

SOP (if available)

Max. file size: 25 MB.

Will you be providing any necessary supplies for this study?*

Yes

Please provide details for supplies

Flush Solution*

Preservation Solution*

Shipment Preservation Method*

Dry Ice

Wet Ice 4℃

Ambient

Please outline your preferences for packaging and labeling*

Additional Comments

Biospecimen Delivery/Logistics

Will CORE be responsible for setting up shipment?*

Yes

Please list times available to receive specimens below:

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Receiver's Name*

First Last

Receiver's Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Do you have a preferred courier?

Yes

Courier Name*

Other Preferred Courier*

Courier Phone Number*

Courier Account Number*

Additional Information/Details

Finance/Billing Information

Billing Contact*

First Last

Billing Contact Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone Number*

Email Address*

Proposed Reimbursement Fee*

Donor Family Considerations

Will the site of recovered specimens have any effect on funeral arrangements?*

Yes

Will project results potentially require information be shared or disclosed to family?*

Yes

Will the study require follow-up or contact with the family after obtaining initial consent?*

Yes

Will the family have an opportunity to receive outcomes from the study?*

Yes

Disclaimers and Grants

CORE must be acknowledged in publications arising from research using human cells, tissues or organs supplied through CORE*

I agree

Any human cells, tissues, organs, biomaterials and any data received through CORE will be used only for the purposes stated in this application*

I agree

Final Submission

Additional File Upload if any

Max. file size: 25 MB.

Signature*

Please enter today's date*

MM slash DD slash YYYY

Number

Name

This field is for validation purposes and should be left unchanged.