Application for use of rhic phlebotomy Service

Application and contract for use of Rochester Human Immunology Center

Blood Resource

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 Blood Resource 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. ______________________________________________________________________________ ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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)_____________________________________________________

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 #12011 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

Expiration date of account number____________

___________ 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

PI Signature___________________________________ Date_________________

RHIC Director__________________________________ Date_________________

Sally Quataert, PhD

Fee schedule for use of RHIC Phlebotomy service:

Service Level 1* ^	$75
Service Level 2* ^	$100
Extra charge for CPT tubes	$7.06 each (current as of November 2011)
Service Level 3** ^ (for obtaining unit of blood)	$205
Service Level 4`` (RSRB #12011 450mL unit of blood as available)	$100 (no honorarium is paid for these units)
Parking vouchers for subjects (as needed)	Included in above fees

* Our collaborators are asked to cover the cost for the nurse coordinator's time recruiting volunteers, performing the comprehensive health survey or health update, phlebotomy, phlebotomy supplies, etc.

^ In addition to these changes, you will be charged for the honorarium to the subjects according to the sliding scale in the Healthy donor protocol where the appropriate range is $10-$55.

** Our collaborators are asked to cover the cost for the coordinator's time, honorarium, and blood bank charge.

`` Collaborators are asked to cover the coordinator's time and transportation for retrieval of the unit.

All costs are current as of 11/21/11 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.

RHIC Blood Resource application/contract rev. 11/21/11