Research Study Checklist for Encapsulations

STUDY NAME:

UW BILLING (BUDGET #) OR INVOICING (CONTACT PERSON’S NAME & BILLING ADDRESS)?:

DRUG(S):

AMOUNT(S) NEEDED FOR EACH DRUG:

WHEN FIRST NEEDED:
(PREPARATION REQUESTS MUST BE MADE AT LEAST 6 WEEKS PRIOR TO NEED.)

AMOUNT(S) NEEDED FOR EACH DRUG, AND FOR WHAT INTERVAL? (HOW OFTEN?);
(PREPARATIONS MUST BE USED WITHIN SIX MONTHS, OR WILL BE BEYOND-USE.)

ESTIMATED LENGTH OF STUDY PERIOD:

DO ACTIVES & PLACEBOS HAVE TO MATCH?:

ANY CAPSULE SIZE RESTRICTION?:

CAN LACTOSE BE USED AS FILLER?:

IF CONTROLLED SUBSTANCE DRUG(S) USED,
NEED CURRENT COPY OF REGULATORY AGENCY(S)
CONTROLLED SUBSTANCE REGISTRATION(S):

WHO WILL DISPENSE, PACKAGE, LABEL,
ADMINISTER STUDY MEDS?:

WILL DRUGS BE PICKED UP FROM DRUG SERVICES OR DELIVERED TO ANOTHER LOCATION?

COMPLETE DELIVERY ADDRESS/CONTACT PERSON:

UW IRB APPROVAL?:

COPY OF IRB APPROVAL COVER SHEET FAXED?:

COST FOR PREPS:

• $0.50/CAPSULE FOR LACTOSE PLACEBOS
• $0.75/CAPSULE + DRUG COST FOR ACTIVES
• $0.55/CAPSULE FOR NON-LACTOSE FILLED PLACEBOS
• $1.00/CAPSULE + DRUG COST FOR NON-LACTOSE ACTIVES
• $1.50/CAPSULE + DRUG COST FOR CHEMO ACTIVES
• $3.00/CAPSULE + DRUG COST FOR TABLET-SPLITTING OR SERIAL DILUTION ACTIVES
• $5.00/CAPSULE + DRUG COST FOR HAND-FILLED & INDIVIDUALLY WEIGHED ACTIVES
• $15 SURCHARGE FOR CONTROLLED SUBSTANCES

SHIPPING COST:  $20 POSTAL EXPRESS