Clinical Research Center Service Request Instructions: To request study support from the Baylor St. Luke’s Medical Center (BSLMC) Clinical Research Center (CRC), please complete this form and submit it to IRB of record #: BCM H#: Name: Principal Investigator: Phone: Email: Name: Administrative Contact: Phone: Email: Study Title: Short Title: Brief description of study & purpose: Study Sponsor: funding source: Industry Non-industry CRC Stay Type: In-patient Out-patient Expected project end Expected project start date: date: Total # Subjects to be seen Number of CRC visits at CRC: per subject: Drug Name: IND#: Route of administration: PO IV SQ IM Other: Other Meds (list): Device Name: IDE#: Study Phase NCT # (if available) Time subject is to be seen AM visit PM visit at CRC Weekday Weekend Length of CRC visit - Time: : Estimated Start time and Hours: number of hours: Please indicate CRC Nursing support Room only resources needed Other:_____________________________________ Study procedure(s) to be done at CRC: List of Test/Procedure Number of CRC Staff Study Team Procedure Type (CPT code or Procedure(s) (Research vs SOC) procedure name) per Subject ICF Vital sign Body measurement
Clinical Research Center Service Request Instructions: To request study support from the Baylor St. Luke’s Medical Center (BSLMC) Clinical Research Center (CRC), please complete this form and submit it to IRB of record #: BCM H#: Principal Investigator: Name: Phone: Email: Administrative Contact: Name: Phone: Email: Study Title: Short Title: Brief description of study & purpose: Study Sponsor: funding source: Industry Non-industry CRC Stay Type: In-patient Out-patient Expected project start date: Expected project end date: Total # Subjects to be seen at CRC: Number of CRC visits per subject: Drug Name: IND#: Route of administration: PO IV SQ IM Other: Other Meds (list): Device Name: IDE#: Study Phase NCT # (if available) Time subject is to be seen at CRC AM visit PM visit Weekday Weekend Length of CRC visit - Estimated Start time and number of hours: Time: : Hours: Please indicate CRC resources needed Nursing support Room only Other:_____________________________________ Study procedure(s) to be done at CRC: List of Test/Procedure (CPT code or procedure name) Number of Procedure(s) per Subject CRC Staff Study Team Procedure Type (Research vs SOC) ICF Vital sign Body measurement