The code block below illustrates how one might use # and // as comments in your logic and calculations.

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Required format:

jm3es2pQiQatIHTz6yPKwczFRZ6xHKGIJwrX6X2IU2tpoF9WRozniENBIeGFI5H7AuKgz

Penn CFAR Clinical Core: User Request Form

Thank you for your interest the Penn CFAR Clinical Core. In order to utilize the services of the Penn CFAR Clinical Core, please complete this questionnaire in full. Incomplete information may delay your request. You can expect to be contacted by Clinical Core staff within 5 business days of submitting this form.

If you have any questions, please contact the Penn CFAR Clinical Core Director, Dr. Vin Lo Re, at vincentl@pennmedicine.upenn.edu.

Thank you!

Title:	First Name:	Last Name:
Email:
Phone:
Primary Insitutional Affiliation:
Primary Department:
Primary Division:
Position:
Are you a member of CFAR?
Have you previously used CFAR Clinical Core services?

First Name:		Last Name:
Is the PI also the user named in the section above?

Email:
Primary Insitutional Affiliation:
Primary Department:
Primary Division:
Position:
Is the PI a member of CFAR?

Is this query in preparation for research (e.g., feasibility assessment for a grant application), or is the request related to an existing protocol or grant?

* must provide value

Preparation for research

Existing protocol or grant

reset

Project Title:
Project Summary:
Inclusion/Exclusion Criteria:

IRB of Record:
IRB Protocol #:
Current IRB Approval Letter:

Is there financial support/grant tied to this project?

* must provide value

Yes No

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Funding Type:
Funding Source:		(e.g., NIAID, Pfizer)
Grant #:

Our NIH reporting requirements stipulate that we also collect the following information on NIH-funded projects utilizing our services.

PI indicated on NIH grant:	First Name:	Last Name:
NIH grant type (a.k.a. activity code):
Total dollar amount of awarded funds:		(Numbers only; no $)

Business Administrator:
First Name:		Last Name:
Email:
Phone:

Please indicate the service(s) that you are requesting:

* must provide value

Data request

Specimen request from repository

Prospective collection of patient material

Collaboration with Philadelphia Dept of Public Health

Implementation science support

Mentorship

Recruitment support

Regulatory support

Study design support

Other

Which database(s) are you interested in utilizing?

Adult/Adolescent Database: Database of >3,500 individuals containing clinical, virological, treatment, behavioral, substance use, and other data elements
HIV Prevention Database: Database of 253 men and transgender individuals who have sex with men screening for HIV prevention clinical trials containing behavioral questionnaires, PrEP utilization, and sexual behavior data
Pediatric Database: Database of ~2,500 infants, children, and adolescents with perinatal HIV exposure or perinatally-acquired HIV containing clinical, virologic, and neurocognitive data
Philadelphia Department of Public Health (PDPH): The CFAR Clinical Core will assist with development and submission of Data Analysis Concept Proposals to PDPH for utilization of the following data sources: HIV Surveillance, National HIV Behavioral Surveillance, the Medical Monitoring Project, Perinatal HIV Surveillance, Ryan White CAREWare, Molecular HIV Surveillance Data, and Data to Care. Investigators can also work with the Clinical Core to create and submit data requests for limited data elements from PDPH.
Adolescent STI/HIV Prevention Continuum: Database of >100,000 testing/prescription encounters in >35,000 adolescents, including testing data, geospatial data, PrEP prescriptions, and visit note data for natural language processing

* must provide value

Adult/Adolescent Database

HIV Prevention Database

Pediatric Database

Philadelphia Department of Public Health

Adolescent STI/HIV Prevention Continuum

Are you requesting direct access to the Adult/Adolescent Database?

* must provide value

List of data elements you would like to gather:

* must provide value

Expand

What type(s) of specimen is being requested?

* must provide value

Expand

Regulatory support is requested for which institution(s)?

* must provide value

Penn

CHOP

Wistar Institute

Other

Please use this space to provide additional details on the support that you are requesting:

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I, ______ ______, confirm that any and all data/specimens viewed/obtained will be used for research purposes conducted at Penn CFAR affiliated institutions (University of Pennsylvania, Children's Hospital of Philadelphia, the Wistar Institute) and in accordance with relevant research protocols. Additionally, we will acknowledge the Penn CFAR (P30 AI 045008) in any presentations or publications that utilize CFAR services.

* must provide value

Add signature

Date of Request

* must provide value

M-D-Y

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