TRIP Service Request
TRIP Fee Schedule
UWHC Surgical Pathology Archived Tissue Request Form
UWHC Surgical Pathology Archived Tissue Request Form Guide
Pathology & Laboratory Medicine
Technical Contact Name
Technical Contact Email
Technical Contact Phone Number
Billing Contact Name
Billing Contact Email
Billing Contact Phone Number
Who is the collaborating pathologist involved in the project (if applicable)?
Funding Source (ex. ICTR, NIH):
Fund # (ex. 135,144):
Account UDDS (ex. 536300):
Project # (ex. PRJ33XL):
Is this a human subjects research project?
If yes, indicate the following:
UW Study Protocol number (ex. UW13050)
IRB approval number (ex. 2015-1340):
IRB approval expiration date:
Duration of human subjects research study:
In addition, to commence work on a human subjects research project, please submit the following materials to email@example.com
ARROW-approved IRB application
Approval memo for initial protocol and amendments
Study protocol and lab manual
If samples need to be de-identified, please e-mail a coding sheet for slide labeling.
Project/Service request description & testing required:
IMPORTANT: DO NOT INCLUDE PATIENT INFORMATION OR PATHOLOGY ACCESSION NUMBERS.
E-mail this information to firstname.lastname@example.org
You can include de-identifiedinformation in the project description.
Does the project have any time constraints? (i.e. grant deadlines, funding deadlines, etc.)
Anticipated project start date:
Optimal completion date: