IDS Multi-Site IP Request

Please complete this form to provide approval of a shipment of bulk investigational products for the specified study

Protocol Title

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Protocol Number:

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Site Number (if applicable)

Site Name(if applicable)

Principal Investigator:

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Shipping Address

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Requestor Name (first & last name)

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Requestor Email

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Requestor Phone Number

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I attest that the sponsor, PI, and IRB have approved the shipment of the Investigational product, and documentation can be provided upon request.

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Yes

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I understand that Investigational Product will be shipped within the range of protocol mandated storage conditions but shipments will require a temperature monitor and special packaging (if necessary).

* must provide value

Yes

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Date Needed By (Shipments are overnight, can only be made M-TH and no less than 10 business days from the submission date of this form):

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M-D-Y

Controlled Substance

Yes

Name of Receiving DEA Registrant

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Recieving DEA Registrant Number

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