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Required format:

JRwDv8kZTJBX6vpYgo7QTTxoktgjQ37mdQgfxXGrwr4qsbFWatwotCGeACAEPqJTW4G4pgWIqnbdZBBYCXJtadRTiicCHbqkbX5fEc3goQsNLxMLCb4Hob6BccsmiXh

Freezer Storage Intake Form

Returning?

A A A

The Lifespan Clinical Research Center will attempt to accommodate any short term request for freezer space for storage of research specimens in the Multiphasic Building of Rhode Island Hospital.

Please note, approval must be granted prior to storing any specimens as space is limited. Please submit the form below and someone will reach out. If you have any questions, please contact Amy Palmisciano at 401-793-8788. Thank you!

Requestor's Name (Last, First):

* must provide value

Requestor's email address:

* must provide value

Requester's Phone Number:

Investigator's Name (last, First)

Investigator's email address:

Project Department Affiliation

* must provide value

Protocol/Investigational Plan:

Upload file

Lab Manual:

Upload file

Emergency Contact Name (Last, First):

Note: if specimens need to be re-located in the case of an emergency (i.e. power failure of freezer):

* must provide value

Emergency Contact Phone Number

* must provide value

Storage Temperature Desired:

* must provide value

-20

-80

All of the Above

Start Date of the Storage:

* must provide value

M-D-Y

Duration of Storage (Weeks, Months, Years)

* must provide value

Specimen Types

* must provide value

Whole Blood

Serum

Plasma

Tissue

Saliva

Urine

Stool

Swabs

Other

If other, please explain:

Expand

Maximum number of specimens at any given time

Are Processing and/or Shipping Services needed?

* must provide value

Yes

May Be

reset

Is the requester or investigator familiar with OnCore?

* must provide value

Yes

reset

Do you require storage boxes?

* must provide value

Yes

May be

reset

Has this project been approved by the IRB?

* must provide value

Yes

reset

if yes, please attach the most recent approval letter. This can be either the initial or a continuing review

* must provide value

Upload file

date and time:

* must provide value

M-D-Y H:M

date and time:

* must provide value

M-D-Y H:M

date and time:

* must provide value

M-D-Y H:M

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