Request for UW HIV Information System (UWHIS) Data, Specimens, and Referral Services

Investigators requesting specimens or referral services, please contact the UW HIV Specimen Repository Manager, Michalina Montaño, who will assist you in completing this form. (206-744-4630 - micham@uw.edu)

Investigators requesting clinical data may contact the UWHIS Research Assistant, Matthew Jackson, for assistance. (206-685-7791 - mkj5@uw.edu)

Please allow two weeks for fulfillment of each submission; for requests needed in a shorter amount of time, the Data Manager, Peggie Griffith, may be contacted to discuss expedited service. (206-744-3683 - peggieg@uw.edu)

 

Request Type
Do you have approval for patient identifiers to be included in your dataset?
Grant Application Information
Grant Application Source
Is the PI of the grant application the same person as the study investigator?
Grant Application PI Information
Study Investigator Information

If you are filling this form out on someone else's behalf, please use their information, not your own.

NIH Reporting

Please provide the following information required by CFAR for NIH reporting.

Study Investigator professional status
Study Investigator NIH Funding Status
Additional NIH Reporting (Please select all applicable fields)
Contact Information
Grant Information
Source of grant funding this study
Is the grant PI the same person as the study investigator?
Grant Application PI Information
Study Information and Data Request
Study Subjects
Study Time Frame
Recruitment/Referral Information
Clinic Space Requested
Data Elements

Please list the discreet data elements that you are requesting for each study subject/specimen.

Specimen Information
Type of specimen
Signature