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

# Text can be put here to explain what the logic/calculation does and why.
if ([field1] = '1' and [field2] > 7,

	// This comment can explain what the next line does.
	[score] * [factor],

	// Return '0' if the condition is False.
	0
)

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Required format:

Survey, Recruitment, and Biospecimen Collection Shared Resource (SRBSR) Service Request From

Please complete the SRBSR service request form and someone from our team will get back to you shortly.

Thank you.

Principal Investigator Information

Today's Date

* must provide value

M-D-Y

First name

Last name

Department

Program

Other Program

Phone

* must provide value

Project Information

Title

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Brief overview of the project

Expand

Is there another contact person for this proposal aside from the PI?

Yes

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Contact Person Name

Contact Person Email

Projected Start Date

M-D-Y

Projected End Date

M-D-Y

IRB Status

Exempt

Plan to submit

Submitted and pending review

Approved

Use GMR2 protocol, if applicable

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Protocol/ IRB Number

Funded Research

* must provide value

Funded research

Unfunded research

Not yet funded (project planning stage)

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Medstar or Georgetown Internal Account Tracking (Must be completed for funded projects)

Source of Funding

National Institutes of Health

Department of Defense

Department of Veterans Affairs

American Cancer Society

Georgetown University (Internal Funds)

MedStar Health Research Institute (Internal Funds)

Other

Please specify the NIH institute

eg: National Cancer Institute(NCI), National Center for Advancing Translational Sciences (NCATS), National Institute of Dental and Craniofacial Research (NIDCR) etc

Other Funding Source

Funding Agency Project Number:
-- Grant
-- Contract
-- Other Funding Source Provided ID Number

Formal Grant Title (if different from title above)

Worktags

Worktags available?

Yes

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GMS Cost Center (CC)

* must provide value

GMS Fund Code (Fund)

* must provide value

GMS Purpose Code (PP)

* must provide value

GMS Program Code (PG)

* must provide value

GMS Grant Code (Starts With GR)

GMS Assignee Code

* must provide value

GMS Gift Code (BG or EG)

Expiration Date

* must provide value

M-D-Y

Services Requested

What is the main purpose of your request for SRBSR?

* must provide value

Project planning - obtain number of available cases for planning purposes

Recruitment of new subjects for patient-level data collection and/or biospecimen data collection

Accessing stored biospecimen for analysis

Database programming for survey and subject tracking

Data Management and other consulting services (no recruitment or access to existing data)

Medical Record Abstraction

What type of data are you interested in? Please check all that apply.

Biospecimen

Survey (Georgetown Medstar Registry Study)

Medical Record

Do you plan to use existing data or do you want new data?

Existing data

New data

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Please describe your request:

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Characteristics of Subjects Requested for Research Project

* must provide value

Cancer cases

Non-cancer cases

Institutions Participating

MGUH

MWHC

What is the target enrollment size for cancer cases?

What is the target enrollment size for non-cancer cases?

Cancer Type(s)

All Cancers

Breast

Colon

Rectal

Leukemia

Lymphoma

Ovarian

Cervical

Lung

Pancreatic

Prostate

HCC

Other

Cancer Type(s)

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Other:

Type of subjects [non-cancer cases]

Patients at high risk of cancer (genetic mutation carriers)

Primary care patients/internal medicine

Other specialty clinic populations

If high risk: For which cancer types?

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If high risk: Which mutation carriers?

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If specialty clinic: Which clinics or departments? (e.g. Gastroenterology, Endocrinology, Neurology, Psychiatry)

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Age at Diagnosis [cancer cases]

Minimum:

Maximum:

Age [non-cancer cases]

Minimum:

Maximum:

Years of Diagnosis [cancer cases]

Start:

End:

Age at Specimen Collection (if applicable)

Minimum:

Maximum:

Sex

Male

Female

Racial or Ethnic Groups

Non-Hispanic Whites

Non-Hispanic Blacks

Hispanic

Asian

Other

Vital Status

All patients

Only alive

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Alive as of date:

M-D-Y

Time Since Diagnosis

Newly diagnosed

Within 1 year

Within 3 years

Within 5 years

Other

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Other:

Other Inclusion Criteria

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Exclusion Criteria

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Identification and Potential Recruitment of New Subjects

Do you want SRBSR to screen and identify eligible patients for your project?

Yes

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Do you want SRBSR to recruit eligible patients for your project?

Yes

No, I will use someone else to do the recruitment

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When do you want to initiate recruitment services?

Month:

Year:

Do you want SRBSR to consent subjects and/or administer the surveys to them for your project?

Only consent subjects

Only administer surveys for subjects

Consent and administer surveys for subjects

No consenting or administrating of surveys needed

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Database programming for survey and subject tracking

Do you want SRBSR to assist you with designing a patient-level survey for your project?

Yes

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What type of survey would you like to use?

Web

Paper

Phone

What general domains or variables will be included in the survey?

Sociodemographics

Clinical

Behavioral

Quality of life

Symptoms

Function

Other

If quality of life, did you have a specific scale or instrument you want to use?

PROMIS

SF-36

Other

Other scale or instrument:

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Other:

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How many timepoints will the survey cover?

5 or more

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Do you want SRBSR to create a database to manage survey data for assessment and tracking purposes?

Yes

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Do you have a preference for which program?

REDCap

Qualitrics

Tonic

Other

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Other:

Biospecimen Request Information

Do you want biospecimen samples?

Yes

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Type of Biospecimen

Blood

Urine

Stool

Saliva

Bone marrow aspirate

Type of Blood Collection Tubes

Red

Green

Purple

Mouthwash

Urine

Other

Other:

[Red] Number of tubes requested

[Green] Number of tubes requested

[Purple] Number of tubes requested

[Mouthwash] Number of tubes requested

[Urine] Number of tubes requested

[Other] Number of tubes requested

Liquid products

Plasma

Serum

Whole blood

Blood clot

Buccalcells

RBC

Buffy coat

[Plasma] Number of samples

[Serum] Number of samples

[Whole Blood] Number of samples

[Blood Clot] Number of samples

[Buccalcells] Number of samples

[RBC] Number of samples

[Buffy Coat] Number of samples

Additional data and/or information

Expand

EMR Data

Do you want SRBSR to obtain data from the EMR for your project?

Yes

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Do you have an abstraction form?

Yes

reset

Do you need help from SRBSR to create an abstraction form and manual?

Yes

reset

Please select all applicable variables to be abstracted from the EMR for your study.

Cancer diagnosis of interest, as applicable

Cancer status at recruitment

Sex

Race/ethnicity

Vital Status

Stage

Grade

Histology

Biomarkers

Comorbidities

Treatment

Disease status

Other

Please specify other variables you want to abstract from the EMR record

Expand

Please specify biomarker(s) needed:

HER2

ER/PR

Other

Other biomarker(s)

Please specify treatment(s):

Surgery

Radiation

Chemotherapy

Other

Other treatment(s)

Expand

Data Management and other consulting services
(No recruitment required)

Do you need data management consultation services to discuss best practices and how to support your projects specific data needs?

Yes

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Do you need consultation on survey applications to use, such as REDCap, Qualtrics, Tonic, etc.?

Yes

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Do you need consultation on survey measures to use?

Yes

reset

Do you want SRBSR to assist you with designing a patient-level survey for your project?

Yes

reset

What type of survey would you like to use?

Web

Paper

Phone

What general domains or variables will be included in the survey?

Sociodemographics

Clinical

Behavioral

Quality of life

Symptoms

Function

Other

If quality of life, did you have a specific scale or instrument you want to use?

PROMIS

SF-36

Other

Other scale or instrument:

Expand

Other:

Expand

How many timepoints will the survey cover?

5 or more

reset

Do you want SRBSR to create a database to manage survey data for assessment and tracking purposes?

Yes

reset

Do you have a preference for which program?

REDCap

Qualitrics

Tonic

Other

reset

Other:

Expand

Do you need SRBSR to help with instrument scoring (e.g. PROMIS)?

Yes

reset

Do you need data cleaning and preparation for self-collected or secondary data?

Yes

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Please describe the data that you have:

Survey data

Medical records

Claims

Other

Do you need SRBSR to help with data reporting (NCI reporting, external site reports, accrual reports, etc.)?

Yes

reset

Do you need SRBSR to conduct educational development, training, workshops?

Yes

reset

Detailed Study Information

Please upload the following documents for SRBSR to review.

Please email Colleen McGuire (mcguirec@georgetown.edu) or Tania Lobo (tania.lobo@georgetown.edu), SRBSR Directors of Operations, with any questions or concerns that you'd like address immediately.

1. Abstract

Upload file

2. IRB Approved Study Protocol (if applicable)

Upload file

4. Other study documents

Upload file

Disclaimer and Signature

Acknowledgement

Publications and/or grants arising from research projects using SRBSR specimens and/or data must acknowledge this support by stating "Samples and/or data were provided by the Survey, Recruitment and Biospecimen Shared Resource of Lombardi Comprehensive Cancer Center, which is partially supported by National Institutes of Health Grant P30-CA-51008 (Cancer Center Support Grant to Lombardi Comprehensive Cancer Center)."

*Note: Revisions to the above specimen and/or data request will be subject to re-review and approval by SRBSR. When applicable, the project fees and estimate may be revised to reflect ongoing project support and/or expansion.

PI Signature

Add signature

Date

M-D-Y

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