Pathology Queensland

Client Services

APPLICATION FOR SERVICES – Clinical Trials and Research

Privacy Notice: Personal information provided in this application will be handled in accordance with the Information Privacy Act 2009 (Qld) by Pathology Queensland (Client Services). Pathology Queensland (Client Services) is collecting information in order to progress agreements and pathology services within Pathology Queensland’s laboratories. All personal information will be securely stored and only accessible by authorised persons. Your personal information will not be disclosed to other third parties without consent, unless required by law. For information about how Queensland Health protects your personal information, or to learn about your right to access your own personal information, please see our website at www.health.qld.gov.au.

PROJECT INFORMATION

Application Date
Protocol or Project Number
HREC Reference Number
Project Description (Long Name)
Project Title (Short Name)
Laboratory / Site at which services are requested
Other Queensland Public Hospital Sites for this project
Ward/Unit (if applicable)
Expected Start Date
Expected Completion Date
Number of Patients Estimated	Number of visits (per patient)
Yes / No
Type of Project	Contract
Collaborative and Internal with Pathology Queensland (Please contact PQ Research Office PQ-Research@health.qld.gov.au)
Funding (select all that apply)	Commercial
University
NHMRC
QLD Health
In-kind Contribution (average time / week)
Other (e.g., National funding, state-based funding) (Please specify):

PRINCIPAL INVESTIGATOR / REQUESTING RESEARCHER

Sponsor Contact	Name: Organisation: Email: Phone:
Principal Investigator (PI)	Name: Organisation/HHS: Email: Phone:
Site Coordinator	Name: Organisation/HHS: Email: Phone:
Clinical Unit

NAME OF REQUESTING OFFICERS / CLINICIANS

Consultant	Name: Organisation/HHS: Email: Phone:
Requesting Officer	Name: Organisation/HHS: Email: Phone:
Additional Requesting Officer (if applicable)	Name: Organisation/HHS: Email: Phone:

PREFERRED CONTACT FOR SAMPLE / REQUEST FORM QUERIES

Contact 1	Name: Email: Phone:
Contact 2	Name: Email: Phone:

PATHOLOGY REPORTS - Please note reports are automatically generated and contain patient identifiers. For this reason, the listed contact must be the Queensland Health Principal Investigator or study team who would normally have access to identifiable health information for this project. Reports should not be sent direct to sponsors and any de-identification is the responsibility of the clinical team.

Yes / No
Are Printed Pathology Reports Required?
If Yes, Name and Address for Reports	Name: Organisation/HHS: Address: Fax:
Yes / No
Will you Require Secure Electronic Reporting?
If Yes, Select Preferred Option Below
Yes / No
kiteworks™ (External to QLD Health Only)
Name: Organisation: Email Address:
Yes / No
Encrypted Email (multiple email addresses can be included)
Name: Organisation/HHS: Email Address:

INVOICE INFORMATION – Please note invoices are automatically generated and contain patient identifiers. For this reason, the listed contact must be the Queensland Health Principal Investigator or study team who would normally have access to identifiable health information for this project. Invoices should not be sent direct to sponsors and any de-identification is the responsibility of the clinical team.

Name and Address for Invoice	Name: Email: Address:
Complete Details Below as Applicable
QLD Health Cost Centre (CC)
Internal Order Number (ION)
PQ Research Committee Number (PQRC)
Purchase Order Number (PO)

PATHOLOGY QLD LABORATORY SERVICES REQUIRED FOR PROJECT

Pre-Analytical Processing - Please supply Laboratory Manual or equivalent.

Blood Specimen Collection (by Pathology Qld phlebotomy staff)

Centrifugation / Aliquoting

Centrifugation / Aliquoting outside standard business hours (Mon – Fri 8am – 5pm)

Please note this service is pending additional approval which is not guaranteed.

Subject to laboratory staff resourcing

Will incur an additional cost.

Shipping (by Pathology Qld laboratory staff, IATA compliant sites only)

Sample Storage (only available at specific sites)

- 80°C
Number of Samples	Storage Length (months):
- 20°C
Number of Samples	Storage Length (months):

Laboratory Tests – Please supply study protocol.

Please note, this section is for study specific local testing only. Testing for routine patient care does not need to be included here.

Tests

Please Include Specimen Type if Applicable
Yes / No
Is Batch Testing Required?
If Yes, How Many Samples and at What Frequency will they be Delivered? Does this apply to all the requested testing?
Yes / No
Do you require the samples to be returned to you after testing is complete?
Please Provide Return Details (Transport and packaging to be arranged by client)	Name: Address: Phone:

Yes / No
Do you Require Access to Diagnostic Material (FFPE Blocks / Slides, blood or other)?
If Yes, Please Provide Details Do you have patient consent or waiver of consent? Do you have PHA approval to access and use patients’ confidential information? An MTA may be required for samples being sent externally.
Yes / No
Do you Require the Collection of Bone Marrow for Research (above Standard of Care)
If Yes, Please Provide Details (For example; Aspirates, biopsies, slides)

ACCESS TO INFORMATION IN DATABASE – Additional approvals may apply.

Yes / No
Do you require access to information in the AUSLAB / AUSCARE database?
Will you need CISSU to extract data for use in this project?
If yes, do you require a copy of the AUSLAB / AUSCARE data request emailed to you?

REQUIRED PATIENT IDENTIFICATION – Samples and request forms.

Yes / No
Hospital UR Number
De-Identification
Other (please specify)

ADDITIONAL INFORMATION

Please attach requested documents and additional information and email to:

PATHOLOGY QUEENSLAND CLIENT SERVICES

PathQldClients@health.qld.gov.au

Pathology Queensland
Central Laboratory
Level 3, Block 7, RBWH

Herston, QLD 4029	General Enquiries 07 3646 60040

Notes

Ethics approval is the responsibility of the researcher.

Research governance approval (if required) is the responsibility of the researcher.

Please allow up to 14 days from application to setup completion

Complex requirements and incomplete applications can increase this turnaround time.

There will be a one-off setup fee, payable upon acceptance of the quotation.