The code block below illustrates how one might use # and // as comments in your logic and calculations.

This value you provided is not a number. Please try again.

This value you provided is not an integer. Please try again.

The value entered is not a valid Vanderbilt Medical Record Number (i.e. 4- to 9-digit number, excluding leading zeros). Please try again.

The value you provided must be within the suggested range

The value you provided is outside the suggested range

This value is admissible, but you may wish to double check it.

The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).

This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.

This field must be a 10 digit U.S. phone number (like 415 555 1212). Please re-enter it now.

This field must be a valid email address (like joe@user.com). Please re-enter it now.

The value you provided could not be validated because it does not follow the expected format. Please try again.

Required format:

RRSPnIZHWcgK4Hhuso9jugyYX6p8pvttxMcxyIoBNfp4GYsG6Dq

Biospecimen Request Form

This form serves as the starting point for receiving biospecimen samples from the Specimen Procurement Service Center (SPSC) associated with the Stephens Family Clinical Research Institute (SFCRI).

There is a save and return option at the bottom of this form in the event you need to locate additional information prior to completing the request.

You will receive a response to this request within 3-5 business days. A Materials Transfer Agreement (MTA) will be executed prior to the delivery of any samples.

Please review the SPSC Terms document for detailed information about the practices that govern this service.

Click on the following link to access the SPSC Terms.

Attachment:SPSC Terms V1.pdf

Do you need PHI for requested samples?

Yes No

reset

Have you completed a Research Services Request Form?

Yes No

reset

When PHI is required, the Research Services Request Form must be completed prior to requesting biosamples. Please complete this form prior to making a request for samples. Clicking on the form link will open the form in a new window. You may exit the Biospecimen request form and return to complete it after submitting the Research Services Request Form.

Project Title

Expand

Has the project been reviewed and/or approved by an IRB?

Yes

reset

IRB # for project

IRB Expiration Date

M-D-Y

Date biospecimens are needed:

M-D-Y

Principal Investigator First Name

Principal Investigator Last Name

Workplace

Indicate clinical area or department

Please specify

Principal Investigator Email

* must provide value

Principal Investigator Phone

Is the primary contact person for this request someone other than the Principal Investigator?

Yes

reset

Contact Person First Name

Contact Person Last Name

Email Address

Phone Number

Anatomic Site

Expand

Slides

Plasma

Serum

Whole Blood

Fresh Tissue

Other

Number of slides

Number of plasma samples

Number of serum samples

Number of whole blood samples

Number of fresh tissue samples

Please specify

Please include specific biospecimen collection, processing, and storage needs below:

Expand

You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.

Biospecimen Request Form

Project Contact Information

Biosample Request Details

You have selected an option that triggers this survey to end right now.