Research Form

Clinical Research for Laboratory Medicine: Initial Feasibility Intake Review Form

Purpose: To evaluate the impact of the proposed project on Sonora Quest Laboratories, LLC (SQL) and/ or Laboratory Sciences of Arizona, LLC (LSA) (a subsidiary of Banner Health) facilities and personnel prior to project submission.

Instructions: Complete all required fields on this form. Incomplete forms may be rejected. The SQL/LSA Research Committee will review the form to determine project feasibility. If the project receives initial approval a second, more detailed project-specific feasibility form will be sent to the Principal Investigator (PI)/Study Project Lead for completion and submission. The completed study specific form will be reviewed by the SQL/LSA Research Committee. A determination will be made and the project PI will receive an outcome email stating the ability of the laboratory to support the project. Both initial and secondary laboratory approvals are required to move forward with submission of the project to the appropriate research oversight committee.

Project/Study Type Definitions: Click here to view the definitions for questions 23 through 28

Do not include any proprietary or confidential information on this Intake Form. If you need to share proprietary information with us regarding your proposed research project, please email ResearchIntakeDashboard@sonoraquest.com and we will provide a secure method of transmission.

Sections marked with an asterisk (*) are required

Principal Investigator (PI) / Study Project Lead

1. Email Address *

2. First Name *

3. Middle Initial *

4. Last Name *

Credentials

5. Choose one of the following *

Contact Information

6. Institution/Organization *

7. Department/Division *

8. Street Address *

9. City *

10. State *

11. Zip Code *

12. Primary phone number *

13. Secondary phone number (optional)

Affiliations: Check all that apply

14. Affiliations *

Other/Specify

CITI Training

Principal Investigators/Study Leads are required to have current CITI certification prior to the start of a research study that will involve collecting protected health information (I.e., scholarly projects, clinical trials, etc.).

15. Does PI/Study Leads have current CITI training? *

16. Institution affiliated with CITI training: *

Project Specifications

17. Title of project *

18. Summary of project: *

19. Will the study require human subject protection, as it relates to drugs, biologics, and/or medical devices (i.e., regulated by the Federal Drug Administration)? *

20. Is this project considered human subjects research or human based bioresearch (i.e., regulated by the Office for Human Research Protections)? *

Project Funding

21. Is the study currently funded? *

22. Expected source of funding: *

NOTE: The fees for research related laboratory services may include, but are not limited to: expendables, labor, shipping and storage. A price quote can be prepared upon request. The final fees will be set forth in the applicable research related agreement.

Project/Study Type

NOTE: Refer to definitions at the beginning of this document to assist you in your selection.

23. Material Transfer *

24. Scholarly Project *

25. Clinical Trial *

26. Laboratory Data/Analytics *

27. Purchase Laboratory Services *

28. Anatomic Pathology *

Additional Contact Information

If you are the individual completing this form and are not the study PI or study lead, please provide your contact information below.

29. First Name

30. Last Name

31. Title

32. Primary Phone Number

33. Secondary Phone Number

34. FAX number

35. Email Address

36. Please provide any additional information specific to what activities will be required by the laboratory.

Please provide any additional information you would like to share with the SQL/LSA Research Committee: Upon submission of this form you will receive a computer-generated email with a project tracking identification number. This number should be referenced on all future project communications.

Disclaimer: This submission does not authorize nor guarantee study participation approval by SQL/LSA entities.