Research Project Application

Thank you for your interest in obtaining biospecimen samples for your research from Donor Network West. The next step toward obtaining biospecimen samples is to complete this application for your project. It is important that you are as specific as possible with details for your research protocol. Upon receipt of your application, our research team will contact you for the next steps. If you have any trouble with your submission, please email asalehi@dnwest.org.

Principal Investigator Information

First Name

Last Name

Position/Title

Institution

Contact Phone #

Email Address

Is Primary Contact Information the same as the Primary Investigator?

YesNo

Primary Contact Information

First Name

Last Name

Position/Title

Institution

Contact Phone #

Email Address

Project Information

Is this a data only request?

YesNo

Do you currently have funding for this project?

YesNo

Project Title

Duration of Study

Abstract (Please copy and paste the project and purpose documentation here)

Data Set Request

Funding

Name of your primary funding source

NIH Institute or Center (If Applicable)

Name any additional sources of funding

Will you require a letter of support for your funding?

YesNo

IRB Approval

YesNoN/A

IRB # (if applicable)

Recovery Information

Recovery by

Donor Network WestOther

If Other, please specify who and enter time frames they are available to recover


Times Available	Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Allocation Information

Please list times available to take calls regarding accepting placement of specimen(s)


Times Available	Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Delivery Location

When are you available to receive specimens? Write in times below


Times Available	Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Contact Person

Phone Number

Street Address

Building/Room

City

State

Zip Code

Courier Information

Courier Name

Contact number

Courier Account Number

Contact Information

Any	Caucasian
Hispanic	African American
Asian	Native American
Pacific Islander