Attachment B Research Requisition/Account Request Form
WUSM Center for Clinical Studies
FAX completed form to: Brittany Ohmeyer Fax #: 747-1404 / Phone # : 747-4000
To obtain preprinted lab/pathology research requisitions, submit this form, signed by Principal Investigator (and
either Department Business Manager or Division Administrator unless funding administered through BJRF). No
signature is required for diagnostic radiology research tests only.
FOR EITHER LAB/PATHOLOGY OR DIAGNOSTIC RADIOLOGY ACCOUNTS, COMPLETE THE FOLLOWING INFORMATION:
Principal Investigator: P.I.’s email :
Phone # : Dept. # : Box # :
Fax # : Sponsor : Protocol # :
Funding Source Federal Industry Dept. Account # :
Brief Study name: ___________________________ IRB or Animal Review Approval # (Required):_____________
Clinical Research Coordinator:___________________________ Phone #:_______________ Fax #:___________
Beeper #:_____________ Campus Box #:_________ Email: ___________________________________
Estimated start date:____est. end date:____ Est. # subjects:___
Human (inpatient or outpatient specify location_______________) Non-human
Charge study to Grant # or Study Account* # (required):___________ Send test reports to: PI or Coordinator
FOR DIAGNOSTIC RADIOLOGY RESEARCH TESTS, COMPLETE THE FOLLOWING ADDITIONAL INFORMATION:
List Diagnostic Radiology tests planned: (include estimated # of each)
Requests for Nuclear Medicine must go through: Terry Thurston 362-2810, Campus Box 8223
Send Radiology billing to: Name:___________________________ Box: ___________ Phone: _______________
You will receive email notice of your radiology account number, which you must enter on the research radiology requisitions.
FOR LABORATORY/PATHOLOGY RESEARCH TESTS, COMPLETE THE FOLLOWING ADDITIONAL INFORMATION: (include required
Call lab/pathology test alerts to: PI or Coordinator Send lab/pathology requisitions to: PI or Coordinator
List lab/pathology tests planned:
(attach additional page if necessary) estimated # specimens per subject:______
Special handling (ex. sample storage, dry ice). If so, you will be contacted by the Center for Clinical Studies (CCS).
ALL lab results will be sent paperless via Clinical Desktop
If you do not wish to receive the results paperless please contact Lisa Tucker-Ruprecht (362-1806) or Johnnie Roe (747-2716)
If research funds in WU account, sign here and get departmental approval By submitting this form, I
agree that my drug, device, grant, or department (for departmentally sponsored research) account for the
above noted protocol shall be automatically charged by the CCS for the research laboratory fees in effect at
the time tests are provided.
Principal Investigator’s signature: ___________________________________________ Date:______________
Departmental Approval Required (Account request cannot be processed without authorized signature.)
Business Manager or Division Administrator:___________________________________ Date:______________
If research funds in Barnes-Jewish (NOT WU) account, sign here By submitting this form, I agree to
pay invoices submitted by the CCS for the above noted protocol for research laboratory fees in effect at the
time tests are provided. I agree to pay these invoices within thirty (30) days after receipt.
Principal Investigator’s signature: ____________________________________________ Date: ____________
BJRF accounts--Send invoices attention:________________________ Box: _______ Phone: _____________
BJRF-studies with grant or study funds administered through Barnes-Jewish Research Foundation, formerly
Jewish Hospital (Office of Research Affairs).
To receive research prices for Lab or Radiology, approval # of appropriate IRB or Animal Review committee is required.
Preprinted requisitions for lab will be provided. Tests will be billed at the research price in effect when tests are completed.
Research lab results will now appear on the BJH computer along with labs ordered for clinical care. Hard copy reports of research results will be sent to the
investigator, and will not be on the lab report for the patient’s permanent record.
Research lab tests are done as routines. Any other special handling must be prearranged.