Lifespan Clinical Research Center

Lifespan Clinical Research Center Freezer Storage Intake Form

The Lifespan Clinical Research Center will attempt to accommodate any short term request for -80C freezer space for storage of research specimens in the Multiphasic Building of Rhode Island Hospital. Please note, approval must be granted prior to storing any specimens as space is limited. Please submit the form below and someone will reach out. If you have any questions, please contact Brittany Phipps 401-793-8571. Thank you!

Basic Information

Requester's Name

First

Last

Requester's Phone Number

Requester's Email

Investigator's Name

First

Last

Investigator's Phone Number

Investigator's Email

Project Title

Project Department Affiliation

Please provide an emergency contact, name and phone number, if specimens need to be re-located in the case of an emergency (i.e. power failure of freezer):

Emergency Contact Name

First

Last

Emergency Contact Phone Number

Storage Details

Storage Temperature Desired

Start Date of Storage

Duration of Storage (Weeks, Months, Years)

Specimen Types

Whole Blood

Serum

Plasma

Tissue

Saliva

Urine

Stool

Swabs

Other

Maximum number of specimens at any given time

Additional Information

Are Processing and/or Shipping Services needed?

Is the requester or investigator familiar with OnCore?

Do you require storage boxes?

Is there any additional information relevant to your request?

Please provide availability for a phone call:

Please provide alternate availability for a phone call: