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)* / $75
11-20 tubes (Green top or green and red top tubes only)* / $100
Extra charge for CPT tubes** / $7.08 each (current as of 7/09)
Unit of blood including coordinator’s time, honorarium, and blood bank charge / $170
Hemachromatosis units- 450 mL (as available) / $100 (no honorarium is paid for these units)
Parking vouchers (as needed) / $3.50 each

*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. / $10
30-50ml (3-5tubes) or 2 – 3&1/3 Tbsp. / $15
60-100ml (6-10 tubes) or 4 - 6&3/4 Tbsp. / $20
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.

**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 1 rev. 8/19/09