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CORE Research Application
CORE Research Application
CORE Research Application_ResearchProject
"
*
" indicates required fields
Step
1
of
12
- Principal Investigator
0%
Principal Investigator
Principal Investigator Name
*
First
Last
Position/Title
*
Institution
*
Phone Number
*
Alternate Phone Number
Email Address
*
Website URL:
Is the primary contact information the same as the Primary Investigator?
*
Yes
No
Primary Contact Name
*
First
Last
Primary Contact Position/Title
*
Primary Contact Institution
*
Primary Contact Phone Number
*
Primary Contact Alternate Phone Number
Primary Contact Email Address
*
Project Information
Project Title
*
Purpose of Project/Research
*
Describe Research Project
*
Please use plain English, as we will use this information when approaching families for obtaining consent for your study
Desired Start Date
*
MM slash DD slash YYYY
Do you currently have funding for this project?
*
Yes
No
Source of Funding
*
Do you have IRB Approval?
*
Yes
No
N/A
How would you describe your organization?
*
Local University or Hospital
Outside Donor Service Area University or Hospital
National/Commercial Researcher
Is this a "For Profit" Organization
*
Yes
No
Are you conducting this research as part of a grant or are you in the process of applying for a grant?
*
Yes
No
Would you consider including CORE as a collaborator on this grant project?
*
Yes
No
N/A
Biospecimen Information
Biospecimen
*
If approved, will continue to add to this to match placement sheets, and ideally LLTN
Current offers
Other
Other Biospecimen
*
Tissue Size
*
Whole
Partial
Number of Samples Requested Per Donor
*
Number of Samples Requested throughout duration of Study
*
Frequency of receiving specimens
*
Daily
Weekly
Monthly
Other
Other frequency of receiving specimens
*
Will this biospecimen be recovered by CORE?
*
Yes
No
Recovery By
*
Please indicate your availability for days below:
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Donor Criteria
Min Age
*
Please enter a number from
1
to
150
.
Max Age
*
Please enter a number from
1
to
150
.
Sex
*
Female
Male
Both
Race
American Indian/Alaska Native
Asian
Black or African American
Native Hawaiian
White
Donor Type
*
Brain Death
DCD
Tissue
Inclusion (list any other criteria)
Serologies: Are any of these UNACCEPTABLE
*
HIV
HBV
HCV
RPR
Toxoplasma
Additional Requests
Please Indicate whether the proposed research project involves any of the following:
Donor Data
Yes
No
Medical Device
Yes
No
Study of a Drug
Yes
No
Testing for Genetic Diseases or genetic Markers
Yes
No
Please indicate the Information you will need post acceptance:
Donor Chart
Yes
No
Recovery Details
Yes
No
DRAI
Yes
No
Serologies
Yes
No
Organ Specific Testing
Yes
No
Lab Results
Yes
No
Additional Comments
Allocation Information
How would you prefer to receive offers? (Select all that apply)
*
Email
Phone Call
Text
E-System
Access to DonorNet
Do you need full redacted chart at time of referral?
*
Yes
No
Availability: Can you receive offers 24/7?
*
Yes
No
Please indicate your availability for days below:
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Will this study be seeking research organs and/or tissue from other organizations?
*
Yes
No
Name of Organization
*
Recovery Information
Methodology for Procurement
*
Attach SOP if available
SOP (if available)
Max. file size: 25 MB.
Will you be providing any necessary supplies for this study?
*
Yes
No
Flush Solution
*
Perfadex
Servator B
Researcher Supplied
Saline
Other
N/A
Preservation Solution
*
Perfadex
Servator B
Researcher Supplied
Saline
Formalin
Other
N/A
Preservation Method
*
Dry Ice
Wet Ice 4℃
Ambient
Please outline your preferences for packaging and labeling
*
Additional Comments
Biospecimen Delivery/Logistics
Will CORE be responsible for setting up shipment?
*
Yes
No
Please list times available to receive specimens below:
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Receiver's Name
*
First
Last
Receiver's Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
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Armenia
Aruba
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Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
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Côte d'Ivoire
Denmark
Djibouti
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Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
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Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
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Hungary
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India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Do you have a preferred courier?
Yes
No
Courier Name
*
FedEx
QUICK Courier
Airspace
ATM
NORA
Other
Other Preferred Courier
*
Courier Phone Number
*
Courier Account Number
*
Additional Information/Details
Finance/Billing Information
Billing Contact
*
First
Last
Billing Contact Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Phone Number
*
Email Address
*
Proposed Reimbursement Fee
*
Donor Family Considerations
Will the site of recovered specimens have any effect on funeral arrangements?
*
Yes
No
Will project results potentially require information be shared or disclosed to family?
*
Yes
No
Will the study require follow-up or contact with the family after obtaining initial consent?
*
Yes
No
Will the family have an opportunity to receive outcomes from the study?
*
Yes
No
Disclaimers and Grants
CORE must be acknowledged in publications arising from research using human cells, tissues or organs supplied through CORE
*
I agree
Any human cells, tissues, organs, biomaterials and any data received through CORE will be used only for the purposes stated in this application
*
I agree
Final Submission
Additional File Upload if any
Max. file size: 25 MB.
Signature
*
Please enter today's date
*
Month
Day
Year
Comments
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