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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