Population and Data Sciences Core Request Form

Contact / Requestor name*

First Name

Last Name

Contact / Reqestor Email*

Phone

Principal Investigator, Mentor, or Project lead name*

First Name

Last Name

Principal Investigator, Mentor, or Project lead Email*

Are you and your team CMIR members?*

If not a CMIR member, please consider joining at https://medschool.cuanschutz.edu/cmir

What PDSC services are you interested in ? (Check all that apply)*

Study design consultation Analytic design consultation Access to biospecimens Access to clinical data

What sample type(s) do you anticipating needing access to?*

How much sample volume do you anticipate needing?*

Project Title*

Please give a description of your project including primary aims and what services you anticipate needing from the PDSC. When describing your project please include: 1)Type of subjects (pre-RA, RA, controls, other etc.) 2) How many samples/timepoints per subject and what timepoint? 3)If accessing data as well, please briefly describe what data you would like included (demographics, meds, disease duration, smoking, etc.)? *

Accessing these samples and doing testing will require an IRB approval. Do you already have an IRB approval in place to do this work?*

What is your IRB number?*

If no, do you need help getting an IRB created and submitted? (This is a service we provide).*

Will you be sending your samples and/or data to another institution for testing or analyses?*

If yes, you will be required to get an MTA/DUA in place prior to any samples being shipped/data being shared. Please tell us a little about your plans for that and if you will need support to get this submitted (this is a service we provide)*

What is your current timeline/ what are your timing needs for this project?*

Is this request related to the CMIR Micro Grant or Pilot Program?*

Micro Grants are available. For more information, please visit https://medschool.cuanschutz.edu/cmir/funding-opportunities/micro-grants-rfp

Are you also requesting Core 2 (Mucosal Immunobiology Core (MIC)) services?*

Is there anything else you'd like to tell us about your project or needs?*