Application and contract for use of
Rochester Human Immunology Center
Clinical Procurement Service
Application #__________
Approval ____________
Today’s date____________________
Investigator:_____________________________________
Email:__________________________________________
Phone #:________________________________________
Instructions: Please indicate below a brief description of the assays you plan to perform using blood from the Rochester Human Immunology Center Clinical Procurement Service and return the form to Dr. Sally Quataert. She will then meet with you at which time the remainder of the application/contract will be completed. ______________________________________________________________________________ ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Checklist to be completed/reviewed with Sally Quataert PhD., RHIC Director:
___________Grant supports participation costs for human studies
___________ Work to be done is within the scope of the IRB approved protocols #11935,
#13192, or #1201 for healthy donors, including antibodies to be used and methods to be performed. If the work to be done is outside of this scope, Dr. Quataert has been notified in order to determine whether an amendment to the current protocols can be submitted for the type(s) of experiments planned in conjunction with the blood obtained
___________ Account # to be charged by the RHIC has been reviewed with Dr. Quataert
___________ Fee schedule (attached) has been reviewed with investigator
___________ Procedure for requesting blood reviewed. Form to be emailed to PI and contact
person with instructions for completion following application approval
Contact information:
Contact person (person who will be responsible for compiling and sending blood requests):_______________________________________________
Email:_________________________________________________
Phone #:_______________________________________________
Alternate phone #:_______________________________________
Other individuals to which the weekly blood request reminder should be sent (including email address of each):
1)_____________________________________________________
2)_____________________________________________________
3)_____________________________________________________
4)_____________________________________________________
5)_____________________________________________________
PI Signature___________________________________ Date_________________
RHIC Director__________________________________ Date_________________
Sally Quataert, PhD
Fee schedule for use of RHIC Phlebotomy service:
1-10 tubes (Green top or green and red top tubes only)*
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$75
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11-20 tubes (Green top or green and red top tubes only)*
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$100
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Extra charge for CPT tubes**
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$7.08 each (current as of 7/09)
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Unit of blood including coordinator’s time, honorarium, and blood bank charge
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$170
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Hemachromatosis units- 450 mL (as available)
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$100 (no honorarium is paid for these units)
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Parking vouchers (as needed)
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$3.50 each
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*In addition to these charges, you will be charged for the honorarium to the subjects according to the sliding scale in the Healthy donor protocol:
0-20ml (1-2tubes) or ¾ to 1&1/2 Tbsp.
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$10
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30-50ml (3-5tubes) or 2 – 3&1/3 Tbsp.
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$15
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60-100ml (6-10 tubes) or 4 - 6&3/4 Tbsp.
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$20
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Each additional 50ml. (3&1/3 Tbsp) an additional $5 will be added (up to the maximum that can be drawn in any one visit of 350ml) to compensate for the additional time.
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**CPT tube cost fluctuates frequently and may be adjusted to reflect the most current price
All costs are current as of 7/21/09 and may change based on current cost of supplies. Costs will be re-evaluated by the service on a regular basis and will be updated accordingly. Investigators will be informed of changes in fees as they occur.
RHICCPS application/contract rev. 8/19/09
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