The survey below should be completed to request ancillary services from the VCU Health System. This survey will assist study teams in gathering quotes from ancillaries for budgetary purposes. For more detailed instructions about completing this, please click the attachment below which will provide instructions, samples, and other documentation needed to expedite your request. PI First Name* must provide value
PI Last Name* must provide value
PI E-mail* must provide value
PI Phone Number* must provide value
PI Address (Including Box #)* must provide value
Is there another study contact/coordinator other than the PI?* must provide value
Yes No
Study Contact/Coordinator First Name* must provide value
Study Contact/Coordinator Last Name* must provide value
Study Contact/Coordinator E-mail* must provide value
Study Contact/Coordinator Phone Number* must provide value
Study Contact/Coordinator Address (Including Box #)* must provide value
Is the PI the billing contact?* must provide value
Yes
No
Is the Study Contact/Coordinator the billing contact?* must provide value
Yes
No
Billing Contact First Name* must provide value
Billing Contact Last Name* must provide value
Billing Contact Phone* must provide value
Billing Contact E-mail* must provide value
Billing Contact Address (Including P.O. Box #)* must provide value
Is there a budget negotiator or developer involved other than the above mentioned individuals?* must provide value
Yes
No
Should this individual be contacted for pricing quotes provided from this request?* must provide value
Yes
No
Budget Negotiator First Name* must provide value
Budget Negotiator Last Name* must provide value
Budget Negotiator Phone* must provide value
Budget Negotiator E-mail* must provide value
In what department is the clinical trial managed?* must provide value
Anatomy Anesthesiology Biochemistry Biostatistics Center for Society and Health Center on Health Disparities College of Humanity and Sciences Community Engagement Dermatology Emergency Medicine Family Medicine Healthcare Policy and Research Human and Molecular Genetics Institute for Women's Health Institute of Drug and Alcohol Studies (IDAS) Internal Medicine: Cardiology Internal Medicine: Endocrinology Internal Medicine: Gastroenterology Internal Medicine: General Medicine Internal Medicine: Hematology Oncology Internal Medicine: Infectious Disease Internal Medicine: Pulmonary Internal Medicine: Geriatrics Internal Medicine: Nephrology Internal Medicine: Rheumatology Life Sciences Massey Cancer Center Microbiology and Immunology Neurology Neurosurg Dent Neurosurgery Ob Gyn Ophthalmology Orthopedic Surgery Otolaryngology Parkinson's Center of Excellence Pathology Pediatrics Pharmacology and Toxicology Physical Medicine and Rehabilitation Physiology and Biophysics Psychiatry Radiation Oncology Radiology School of Allied Health School Of Business School of Comm Pub Affairs School Of Dentistry School Of Education School Of Engineering School Of Nursing School Of Pharmacy School of Public Health School Of Social Work School Of The Arts Social and Behavioral Health Surgery VA Medical Center VCU Johnson Center for Critical Care and Pulmonary Research Wilder Sch of Govt & Pub Affairs Other
Study Information Project Short Title* must provide value
Is this study investigator initiated?* must provide value
Yes
No
What is the funding Source?* must provide value
Industry Non- Industry
What is the index, if known, associated with this study?* must provide value
6 digits
Protocol Number* must provide value
NCT Number Click on hyperlink to the left to check and see if your protocol has been assigned a National Clinical Trials number
RAMSPOT ID# (Funding Proposal - FP# if known)
Anticipated Start Date* must provide value
Today M-D-Y
Anticipated End Date* must provide value
Today M-D-Y
Upper limit target accrual of patients at VCUHS* must provide value
Study Locations
Locations where all or portions of this study may be conducted (ex: CRU, ACC4)
Will any patients or study participants be seen, or activities take place, in VCU Health System patient care areas including inpatient units and/or ambulatory clinics, OTHER THAN CRU North 8?* must provide value
Yes
No
If patients or study participants will be seen, or activities take place in VCU Health System patient care areas, OTHER THAN CRU NORTH 8, complete the attached form and review with the nurse manager in charge of that space or unit. The form should then be sent to the Nursing Research Advisory Council (NRAC) at NRAC@mcvh-vcu.edu . VCUHS Policy PC.CP.004-Research in Patient Care Areas .[View Image] Ancillary Services Needed - Must check at least one for your submission to be properly routed and processed Ancillary* must provide value
Anesthesiology
Audiology
Bone Density Scans
Cardiology Request Non-Invasive (EKG/Holter/Stress/Echo)
Cardiology Request Invasive (Cathlab/EP)
CARI (Collaborative Advanced Research Imaging)
Clinical Research Unit
Dermatology
Devices and Supplies
Emergency Room
GI Endoscopy
Home Care
Investigational Drug Services
Labor and Delivery
Neurophysiology (EEG)
OB/Gyn
Operating Room
Ophthalmology
Orthopedics
Pathology and Anatomic Pathology
Pediatric Research Unit
Physical, Occupational and Speech Therapy
Pulmonary/Respiratory Care
Radiology
Register a trial and drug management plan without Investigational Drug Service dispensing
Respiratory Care and Pulmonary Function
Renal Dialysis
Stem Cell Lab
Surgery
Tissue & Data Acquisition & Analysis Core (TDAAC)
Vascular Lab
Whole Room Calorimeter (Metabolic Chamber)
Other
Check 'Other' if the ancillary department you need services from is not listed above
If "Other" please indicate which additional Ancillary Service is required.* must provide value
Please list all services being requested.* must provide value
Will any procedures in this study be performed as standard of care/routine care?* must provide value
Yes No Unsure at this time
If "Yes" please indicate what procedures will be considered standard of care/routine care.* must provide value
You have selected "Register a trial and drug management plan without investigational drug service dispensing". Register a trial and drug management plan without IDS dispensing http://www.investigationaldrugs.vcu.edu/investigator/registertrial.html You have selected "Investigational Drug Services". Investigational Drug Services http://www.investigationaldrugs.vcu.edu/investigator/registertrial.html Please supply the e-mail address for the person to receive email(s) for the requested ancillary service(s) follow-up form(s). THIS SHOULD BE A MEMBER OF YOUR STUDY TEAM.* must provide value
Document Upload IRB Approval Letter
Study Protocol (if IRB approved upload approved protocol here)
Informed Consent/Assent Document(s) (if IRB approved upload approved document here)
Coverage Analysis
Lab Manual
Other Study Document
Submit Save & Return Later
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