Get Duke Pathology Internal Clinical Trial Individual Pathology Materials Request Form

Filling out the Duke Pathology Internal Clinical Trial Individual Pathology Materials Request Form online is essential for submitting requests for pathology materials required in clinical trials. This guide provides clear, step-by-step instructions to ensure a smooth and accurate completion of the form.

Follow the steps to effectively complete the request form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Fill in the 'Trial Name' section with the specific name of the clinical trial associated with your request.
3. Enter today’s date to indicate when the request is being submitted.
4. Select your request type by checking either 'Regular' or 'Rush' for expedited processing. If you select 'Rush', be aware that an additional charge will apply.
5. Provide the Duke IRB number if applicable, along with the Fund Code that relates to the financing of the trial.
6. Fill in the principal investigator’s (PI) name, ensuring correct spelling and complete title.
7. Enter the requestor's name and department to identify who is making the request.
8. Complete the patient’s details, including their full name (last, first, middle) and date of birth in the specified format (mm/dd/yyyy).
9. Supply the requestor's contact information including phone number and email address.
10. Include the patient’s accession number and medical record number to facilitate tracking within the health system.
11. Indicate the date of surgery relevant to the request.
12. Provide the date that written consent was received for participation in the trial.
13. Acknowledge your authorization by signing and dating the form, indicating you are authorized by the PI.
14. List the materials and/or services requested by checking the appropriate boxes, including unstained slides and H&E stained slides, and specify counts and thickness measurements where applicable.
15. Detail any special instructions or requests for the handling of the materials.
16. Complete the sections designated for PATHOLOGY USE ONLY as instructed, including any necessary approvals.
17. Review the totals indicated and available fees like the BRPC Fee before finalizing the submission.
18. Once all sections are filled out accurately, save changes, download the form, or print it for submission as required.

Complete your request form online to ensure timely processing of pathology materials.