University of Pennsylvania
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Clinical Core Query Request Form
Contact: Debbie Gudonis-Senior Research Coordinator
Phone: 215-662-2429
Fax: 215-662-7899
Email: Debbie.Gudonis@uphs.upenn.edu
Type of Service Requested:
( Information from Database
( Specimen from Repository
( Prospective Collection of Patient Material
Briefly Describe Project and Purpose:
_____________________________________________________________
_______________________________________________________________________________________________________________________________________________________________________________________
Study Inclusion Criteria: (Describe data elements you would like to gather or characteristics of patients and specimens)
_____________________________________________________________
_______________________________________________________________________________________________________________________________________________________________________________________
Study Exclusion Criteria:
_______________________________________________________________________________________________________________________________________________________________________________________
|Specimen Request |Number of Vials |
|Serum | |
|Plasma | |
|Cells | |
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Clinical Core
Query Request Form
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Grant Title: _____________________________________________________________
Grant Number: __________________________________________________________
Penn Acct. Number: ______________________________________________________
Affiliated Institution Acct. Number: ________________________________________
IRB Approval Dates: ____/____/____--____/____/____
Name of PI: _____________________________________________________________
Email: _____________________________________________________________
Phone/Fax: _____________________________________________________________
Name of User: ___________________________________________________________
Email: ____________________________________________________________
Phone/Fax: ____________________________________________________________
Name of BA: ____________________________________________________________
Address: ______________________________________________________________
_____________________________________________________________________
Email: _____________________________________________________________
Phone/Fax: _____________________________________________________________
Is the purpose of this query for a grant application? __________________________
Will there be a publication in regards to this query? __________________________
Have you previously used the Database and/or Repository? ____________________
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