Shared Resources Services Request Form

Please use this form to request any University of Puerto Rico Comprehensive Cancer Center Shared Resource services. This form will help Shared Resources centralize its operations and better serve its users. Within this form, you should be able to provide us with information regarding your current/future research project and specific details from the service to be requested.

If you have any questions, contact Dr. Elba V. Caraballo, Director of the Shared Resources and Scientific Operations Division or Mr. Jorge Rodríguez Lebrón, Project Manager.

The option "" can only be selected by itself. Selecting this option will clear your previous selections for this checkbox field. Are you sure?

Select the Facility from which you request services: (select all that apply)

* must provide value

Biostatistics and Bioinformatics Core (BBC)

Human Tissue Engineering Laboratory (HTEL)

Immuno-Oncology Laboratory

Evaluation Core

Research Biobank

Puerto Rico OMICS Center (PROMIC)

Scientific Editing and Communications Core (SECC)

Please choose the option that best describes your current request:

* must provide value

Name:

* must provide value

E-mail:

* must provide value

Phone:

* must provide value

If applicable, phone extension:

Primary institutional affiliation:

* must provide value

Other Institution in the United States:

* must provide value

Other institution:

* must provide value

Which of the following categories best describes your role at the UPRCCC?

* must provide value

Which of the following categories best describes your role at the UPRCCC?

* must provide value

Other role:

* must provide value

Provide mentor's name:

* must provide value

Which of the following describes your current position at the UPRCCC?

* must provide value

Which of the following describes your current position at the UPR?

Please select the Division or Office that better fits you:

* must provide value

Please select your Shared Resource Affiliation:

* must provide value

Is this a project related to the Center for the Promotion of Cancer Health Equity (CePCHE)?

COBRE Grant # 1P20GM148324

* must provide value

Yes

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Project Implementation Phase:

Definitions:

Early Study Design: At this stage, the project is in its infancy and being conceptualized. The aims or research strategy have not been clearly defined, and the project is yet to be sponsored.

Study implementation: The project, proposed aims, and research strategy are clearly defined. It can be sponsored research or not.

Post-Study Implementation: the research project or funding has ended.

* must provide value

Early Study Design

Study Implementation

Post Study Implementation

Other

Not Applicable

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The service requested is related to:

Federal Award Number:

Industry Sponsored Research Award Number:

The service requested is related to:

* must provide value

Project Title:

* must provide value

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Project Principal Investigator:

* must provide value

If applicable, attach your Project Abstract:

Upload file

If applicable, attach a copy of your project AIMS:

* must provide value

Upload file

Assurances details:

Assurance	Assurance Number	Protocol approved until	Attachments
Institutional Review Board (IRB)
IACUC
Other:

Is the study cancer-related?

* must provide value

Yes

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What type (s) of cancer is your study related to?

Bladder

Brain

Breast

Childhood

Colon

Colorectal

Endometrial

Gastric

HIV/AIDS-related cancers

Kidney

Leukemia

Lung

Ovarian

Penile

Prostate

Uterine

Other

What is your study related to?

From which component are you requesting services:

* must provide value

Biostatistics

Bioinformatics

Both

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Biostatistics Service Description:

Study design - Assist in overall study design, including sampling and statistical analysis methodologies.
Power analysis and/or sample size calculation - Determine appropriate sampling methods and sizes, and randomization processes.
Data management and processing - Provide services in data cleaning, preparation, processing, and imputation.
Exploratory data analysis - Conduct in-depth data analysis, covering descriptive statistics and measures of central tendency, dispersion, and location.
Statistical data analysis - Evaluate associations and develop predictive models using statistical distribution, machine learning, and/or meta-analysis.
Data visualization- Create visual representations of complex data.
Statistical reporting and writing support - Assist in the preparation of methods sections for manuscripts or grants.
Consulting - Provide expert support in any aspect of research to assist others in planning robust studies.

Select the service (s) you are requesting from the Biostatistics component:

* must provide value

Power analysis and/or Sample Size Calculation

Study design

Data Management and Processing

Statistical Data Analysis

Data Visualization

Statistical Reporting and Writing Support

Exploratory Data Analysis

Consulting

Other

Other biostatistical service:

* must provide value

Describe the Training Activity you want to request from the Biostatistics Core. Include information about the proposed topic, audience, and expected number of attendants. Be as specific as you can. If you do not have a topic yet, include N/A.

* must provide value

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Power analysis and/or Sample Size calculation-data nature:

Study design data nature:

Data Management and Processing data nature:

Statistical Data Analysis data nature:

Data Visualization data nature:

Statistical Reporting and Writing Support data nature:

Microarrays (Methylation or gene expression)

Exploratory Data Analysis data nature:

Bioinformatics Service Description:

Bulk RNA Seq - Conduct analysis, including data processing, quality assessment, and differential expression analyses.
Single Cell RNA-Seq - Conduct analysis, including data processing, quality assessment, and UMAP plots.
Amplicon Seq (Microbiome 16S/18S/ITS) - Conduct analysis, including data processing, quality assessment, taxonomic assignment, phylogenetic tree building and standard results: alpha and beta diversity, and abundance plots.
SNP Array / Whole Exome Sequencing - Conduct analysis, including data processing, quality assessment, and variant calling.
Custom analysis - Conduct advanced analyses or other services not listed. Subject to approval by BBC team.
Statistical reporting and writing support - Assist in preparing methods sections for manuscripts or grants.
Consulting - Provide expert support in any aspect of research to assist others in planning robust studies.

Select the service (s) you are requesting from Bioinformatics component:

* must provide value

Bulk RNA Seq

Single Cell RNA Seq

Amplicon Seq (16S/18S/ITS; Microbiome)

SNP Array / Whole Exome Sequencing

Shotgun Sequencing

Custom Analysis

Microarrays (Methylation or gene expression)

Consulting

Statistical Reporting and Writing Support

Other

Other Bioinformatic Service:

* must provide value

Describe the Training Activity you want to request from the Bioinformatic Core. Include information about the proposed topic, audience, and expected number of attendants. Be as specific as you can. If you do not have a topic yet, include N/A.

* must provide value

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Provide the following information regarding the samples to be used as part of the Bulk RNA Seq analysis.

Service	Nature of data	Sample Source	Types of samples	Number of samples
Bulk RNA Seq

Provide the following information regarding the samples to be used as part of the Single Cell RNA Seq analysis.

Service	Nature of data	Sample Source	Types of samples	Number of samples
Single Cell RNA Seq

Provide the following information regarding the samples to be used as part of the Amplicon Seq (16S/18S/ITS; Microbiome) analysis.

Service	Nature of data	Sample Source	Types of samples	Number of samples
Amplicon Seq (16S/18S/ITS; Microbiome)

Provide the following information regarding the samples to be used as part of the SNIP Array / Whole Exome Sequencing analysis.

Service	Nature of data	Sample Source	Types of samples	Number of samples
SNIP Array / Whole Exome Sequencing

Provide the following information regarding the samples to be used as part of the Custom Analysis

Service	Nature of data	Sample Source	Types of samples	Number of samples
Custom Analysis

Provide the following information regarding the samples to be used as part of the Microarrays (Methylation or gene expression)

Service	Nature of data	Sample Source	Types of samples	Number of samples
Microarrays (Methylation or gene expression)

Provide the following information regarding the samples to be used as part of the ______ analysis requested

Service	Nature of data	Sample Source	Types of samples	Number of samples
Other: ______

Select the service (s) you are requesting from the Human Tissue Engineering Laboratory:

* must provide value

Consultations

On-site or off-site training

Protocols

Reagents bank

Technical assistance

Organoid biobank

Imaging services

Cryopreservation or storage

Microscope Use - Keyence

Other

Other HTEL Service:

Select the service (s) you are requesting from the Immuno-Oncology Laboratory:

* must provide value

Consultation

Flow Cytometer (Acquisition/Cell Sorting)

ELISA Testing

Multiplex Luminex

Automated Cell Counter

Western Blot Pipeline

Quantitative PCR

Tissue dissociation

Chemiluminescence Plate Reader

Tissue homogenization

Training

Other

Other Service:

* must provide value

Select the specific Flow Cytometer (Acquisition)/ Cell Sorting) service requested:

* must provide value

Antibody labeling

Cell cycle analysis

Cell function

Cell signaling/signal transduction

Cell Sorting

Cytokine and chemokines release

Extracellular marker staining

Functional assays

Immunophenotyping

Intracellular marker staining

Necrosis

Proliferation

Transfected cells (GFP and YFP)

Viability

Flow Cytometer - Antibody labeling - Biological Samples Description

Service	Type of sample	Type of organism	# of samples	# of runs per sample
Flow Cytometer - Antibody labeling

Flow Cytometer - Cell cycle analysis - Biological Samples Description

Service	Type of sample	Type of organism	# of samples	# of runs per sample
Flow Cytometer - Cell cycle analysis

Flow Cytometer - Cell function - Biological Samples Description

Service	Type of sample	Type of organism	# of samples	# of runs per sample
Flow Cytometer - Cell function

Flow Cytometer - Cell signaling/signal transduction - Biological Samples Description

Service	Type of sample	Type of organism	# of samples	# of runs per sample
Flow Cytometer - Cell signaling/signal transduction

Flow Cytometer - Cell Sorting - Biological Samples Description

Service	Type of sample	Type of organism	# of samples	# of runs per sample
Flow Cytometer - Cell Sorting

Flow Cytometer - Cytokine and chemokines release - Biological Samples Description

Service	Type of sample	Type of organism	# of samples	# of runs per sample
Flow Cytometer - Cytokine and chemokines release

Flow Cytometer - Extracellular antigen expression - Biological Samples Description

Service	Type of sample	Type of organism	# of samples	# of runs per sample
Flow Cytometer - Extracellular antigen expression

Flow Cytometer - Functional assays - Biological Samples Description

Service	Type of sample	Type of organism	# of samples	# of runs per sample
Flow Cytometer - Functional assays

Flow Cytometer - Immunophenotyping - Biological Samples Description

Service	Type of sample	Type of organism	# of samples	# of runs per sample
Flow Cytometer - Immunophenotyping

Flow Cytometer - Intracellular antigen expression - Biological Samples Description

Service	Type of sample	Type of organism	# of samples	# of runs per sample
Flow Cytometer - Intracellular antigen expression

Flow Cytometer - Necrosis - Biological Samples Description

Service	Type of sample	Type of organism	# of samples	# of runs per sample
Flow Cytometer - Necrosis

Flow Cytometer - Proliferation - Biological Samples Description

Service	Type of sample	Type of organism	# of samples	# of runs per sample
Flow Cytometer - Proliferation

Flow Cytometer - Transfected cells (GFP and YFP) - Biological Samples Description

Service	Type of sample	Type of organism	# of samples	# of runs per sample
Flow Cytometer - Transfected cells (GFP and YFP)

Flow Cytometer - Viability - Biological Samples Description

Service	Type of sample	Type of organism	# of samples	# of runs per sample
Flow Cytometer - Viability

ELISA Testing - Biological Samples Description

Service	Type of sample	Type of organism	# of samples	# of runs per sample
ELISA Testing

Select the Multiplexing Luminex (Luminex LX200) service requested:

* must provide value

Cancer multiplex

Immunology multiplex

Cardiovascular multiplex

Cell signaling multiplex

Metabolism & Endocrinology multiplex

Neuroscience multiplex

Toxicity multiplex

Multiplexing Luminex - Cancer Multiplex - Biological Samples Description

Service	Type of sample	Type of organism	# of samples	# of runs per sample
Multiplexing Luminex - Cancer Multiplex

Multiplexing Luminex - Immunology Multiplex - Biological Samples Description

Service	Type of sample	Type of organism	# of samples	# of runs per sample
Multiplexing Luminex - Immunology Multiplex

Multiplexing Luminex - Cardiovascular multiplex- Biological Samples Description

Service	Type of sample	Type of organism	# of samples	# of runs per sample
Multiplexing Luminex - Cardiovascular multiplex

Multiplexing Luminex - Cell signaling multiplex- Biological Samples Description

Service	Type of sample	Type of organism	# of samples	# of runs per sample
Multiplexing Luminex - Cell signaling multiplex

Multiplexing Luminex - Metabolism & Endocrinology multiplex- Biological Samples Description

Service	Type of sample	Type of organism	# of samples	# of runs per sample
Multiplexing Luminex - Metabolism & Endocrinology multiplex

Multiplexing Luminex - Neuroscience multiplex - Biological Samples Description

Service	Type of sample	Type of organism	# of samples	# of runs per sample
Multiplexing Luminex - Neuroscience multiplex

Multiplexing Luminex - Toxicity multiplex - Biological Samples Description

Service	Type of sample	Type of organism	# of samples	# of runs per sample
Multiplexing Luminex - Toxicity multiplex

Quantitative PCR Multiplex - Sample description

Service	Type of sample	Type of organism	# of samples	# of runs per sample
Quantitative PCR Multiplex

Tissue Dissociator (DSC 800) - Sample description

Service	Type of Tissue	Expected Cell
Tissue Dissociator (DSC 800)

Date the equipment is requested for use:

* must provide value

M-D-Y

Time the equipment is requested for use:

* must provide value

H:M

Services description:

1. Consultation: advice to clients or research teams to help them improve their planning, evaluation, and overall project execution strategies.

2. Conceptualization of Projects/Programs: assistance in developing and defining new projects or programs, including setting objectives, identifying key components, and outlining methodologies.

3. Data Support/Tracking: assistance in managing, analyzing, and tracking data related to research projects or programs to ensure accurate reporting and informed decision-making.

4. Program evaluation: Systematic methods assess programs' design, implementation, and outcomes to improve effectiveness and inform planning and decision-making.

Needs Assessments: evaluations to identify a population's or community's needs to guide program planning and resource allocation.
Process Evaluations: assessments of the implementation process of programs to ensure they are being carried out as planned.
Feasibility Studies: analyses to determine proposed projects or programs' practicality and potential success.
Outcome Evaluations: analyses to measure the results and impacts of programs to determine if they have achieved their intended goals.

5. Planning: assistance in developing strategic plans to guide the direction or actions of a research project.

6. Surveying instruments development: development of tools and questionnaires used to collect data from specific populations to support research and evaluation efforts.

7. Training and capacity building activities: specific activities designed to enhance the skills and capabilities of individuals or teams to improve their performance and effectiveness.

8. Other: any additional services that support planning and evaluation efforts not covered by the above categories.

Select the service (s) you are requesting from the Planning and Evaluation Core:

* must provide value

Consultation

Conceptualization of projects/program

Data support/Tracking

Program Evaluation

Planning

Surveying instruments development

Training and Capacity Building Activities

Other

Other planning and evaluation service:

* must provide value

Type of evaluation requested:

* must provide value

Needs Assessments

Feasibility Studies

Process Evaluations

Outcome Evaluations

Other

Other type of evaluation:

* must provide value

Describe your intended or actual project/program. Focus on what you aim to achieve in the long term.

* must provide value

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Describe your data collection process and the type of data you currently or plan to collect. Describe mechanisms for storage and a brief description of your data collection needs for reporting or quality control purposes. Be as specific as you can.

* must provide value

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Describe your planning needs. Be as specific as you can.

* must provide value

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Describe your surveying instruments needs. Be as specific as you can.

* must provide value

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Describe the Training Activity you want to request from the Planning and Evaluation Core. Include information about the proposed topic, audience, and expected number of attendants. Be as specific as you can. If you do not have a topic yet, include N/A.

* must provide value

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Select the service you are requesting from the Research Biobank. For each biobank service, please complete a new service request form.

* must provide value

Other Biobank Service:

* must provide value

Transfer type:

* must provide value

Transfer proposal:

* must provide value

Upload file

Were the requested samples transferred to UPRCCC under a valid and executed Material Transfer Agreement (MTA) in accordance with institutional requirements?

* must provide value

Yes

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Provide the number of the Material Transfer Agreement associated with the request:

* must provide value

Type of derivatives

* must provide value

Other derivative:

* must provide value

Which type of biological specimens do you require?

* must provide value

Clinical diagnosis required for biospecimens:

* must provide value

Body Fluids Samples Requested:

* must provide value

Whole Blood (0.5 ml)

Plasma (0.5 ml)

Buffy Coat (1.0 ml)

Serum (0.5 ml)

PBMC's (0.5 ml)

DNA (0.5 ml)

RNA (0.5 ml)

Dried Blood (Spots unpunched circles)

Other

Other body fluid:

* must provide value

______ : Number of Whole Blood (0.5 ml) samples required

Body fluid sample	Cases	Control
Whole Blood (0.5 ml)

What type of ______ do you require for the Whole Blood sample?

Body fluid sample	Cases	Control
Whole Blood (0.5 ml)

______ : Number of Plasma (0.5 ml) samples required

Body fluid sample	Cases	Control
Plasma (0.5 ml)

What type of ______ do you require for the Plasma sample?

Body fluid sample	Cases	Control
Plasma (0.5 ml)

______ : Number of Buffy Coat (1.0 ml) samples required

Body fluid sample	Cases	Control
Buffy Coat (1.0 ml)

What type of ______ do you require for the Buffy Coat sample?

Body fluid sample	Cases	Control
Buffy Coat (1.0 ml)

______ : Number of Serum (0.5 ml) samples required

Body fluid sample	Cases	Control
Serum (0.5 ml)

What type of ______ do you require for the Serum sample?

Body fluid sample	Cases	Control
Serum (0.5 ml)

______ : Number of PBMC's (0.5 ml) samples required

Body fluid sample	Cases	Control
PBMC's (0.5 ml)

What type of ______ do you require for the PBMC's sample?

Body fluid sample	Cases	Control
PBMC's (0.5 ml)

______ : Number of DNA (0.5 ml) samples required

Body fluid sample	Cases	Control
DNA (0.5 ml)

What type of ______ do you require for the DNA sample?

Body fluid sample	Cases	Control
DNA (0.5 ml)

______ : Number of RNA (0.5 ml) samples required

Body fluid sample	Cases	Control
RNA (0.5 ml)

What type of ______ do you require for the RNA sample?

Body fluid sample	Cases	Control
RNA (0.5 ml)

______ : Number of Dried Blood (Spots unpunched circles) samples required

Body fluid sample	Cases	Control
Dried Blood (Spots unpunched circles)

What type of ______ do you require for the Dried Blood sample?

Body fluid sample	Cases	Control
Dried Blood

______ : Number of Other: ______ samples required

Body fluid sample	Cases	Control
Other: ______

What type of ______ do you require for the ______ sample?

Body fluid sample	Cases	Control
Other: ______

Please select the type and storage method for solid tissue ______ and provide the required number of samples. Complete a line for each category or storage of solid tissue requested. If more than five categories of solid tissue are requested, please get in touch with the biobank personnel.

Category	Storage Method	# of cases required	Quantity requested (mg)

Category	Storage Method	# of controls required	Quantity requested (mg)

Other Solid Tissue - #1

Other Solid Tissue - #2

Other Solid Tissue - #3

Other Solid Tissue - #4

As part of the ______, will you be requesting the distribution of a whole tissue block?

Yes

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Provide information on why the whole block is requested:

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Please select the type of biospecimen collection needed for you ______ service. Complete a line for each category or storage of solid tissue requested. If more than five categories of solid tissue are requested, please get in touch with the biobank personnel.

Category	Cases	Controls
______
______
______
______
______

Pathological Services Requested:

Unstained Tissue Slide

Staining: H&E Tissue Slide

Microtomy: FFPE Tissue block sectioning

Microtomy: Frozen Tissue sectioning

Pathological evaluation of tissue slides

Consulting with the Pathologist

Other

Number of Unstained Tissue Slides Requested:

Number of	Cases	Control
Unstained Tissue Slides

Number of H&E Tissue Slides Requested:

Number of	Cases	Control
H&E Tissue Slides

Number of FFPE Tissue block sections required:

Number of	Cases	Control
FPE Tissue block sections

Number of Frozen Tissue block sections required:

Number of	Cases	Control
Frozen Tissue block sections

Number of Tissue Slides for Pathological evaluation:

Number of	Cases	Control
Tissue Slides

Please describe your pathological service consultation needs.

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Please describe your other pathological service needs from the Research Biobank.

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Please describe the biospecimens to be disposed of. Include information regarding the type of biological material, the amount, and the reasons for discarding it.

* must provide value

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Please describe the consulting service you requested from Biobank. Be as detailed as possible.

* must provide value

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Please describe your biospecimen storage needs. Describe aspects such as type and amount of sample, storage conditions, timefreme or frequency of storage, etc. Be as detailed as possible.

* must provide value

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Please describe your data inclusion needs. Be as detailed as possible.

* must provide value

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For emergency storage service requests, please get in touch with Ms. Cristina Castro at Biobank@cccupr.org. Be able to provide the reason for requesting Emergency storage, the type, storage temperature, and amounts of materials to be stored. Additional information might be requested.

Data required to be included with the biological sample as part of the ______

* must provide value

Biospecimen type (cell, fluid, tissue, etc.)

Anatomical location

Collection procedures

Storage procedures

Transfer procedures

Patient demographics (age, sex, place of birth, etc.)

Patient Lifestyles (smoking and drinking habits, nutrition, exercise, etc.)

Patient complaint/history of current illness

Patient's past medical history

Patient family history

Clinical diagnosis

Pathological diagnosis

Patient treatment information

Patient treatment outcomes

Patient consent/authorization status

Quality control data on the biospecimen

Other

I do not require any information on my biological samples.

Not Applicable

Other donors information:

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Select the service (s) you are requesting from the Puerto Rico Omics Center (PROMIC):

* must provide value

DNA extraction and QC

RNA extraction, cDNA template preparation, and QC

Library preparation for sequencing and templates preparation

DNA/RNA sequencing reactions

Affymetrix Microarrays

iScan BeadArrays

Quantitative PCR (QuantStudio6)

Droplet digital PCR (BioRad QX200)

Proteomic Assays

Metabolomics

Other

Other PROMIC Service:

* must provide value

DNA extraction and QC -Biological Samples Description

Service	Type of sample	Type of organism	# of samples	# of runs per sample
DNA extraction and QC

RNA extraction, cDNA template preparation, and QC -Biological Samples Description

Service	Type of sample	Type of organism	# of samples	# of runs per sample
RNA extraction, cDNA template preparation, and QC

Library preparation for sequencing and templates preparation - Biological Samples Description

Service	Type of sample	Type of organism	# of samples	# of runs per sample
Library preparation for sequencing and templates preparation

DNA/RNA sequencing reactions - Biological Samples Description

Service	Type of sample	Type of organism	# of samples	# of runs per sample
DNA/RNA sequencing reactions

Affymetrix Microarrays- Biological Samples Description

Service	Type of sample	Type of organism	# of samples	# of runs per sample
Affymetrix Microarrays

iScan BeadArrays- Biological Samples Description

Service	Type of sample	Type of organism	# of samples	# of runs per sample
iScan BeadArrays

Quantitative PCR (QuantStudio6) - Biological Samples Description

Service	Type of sample	Type of organism	# of samples	# of runs per sample
Quantitative PCR (QuantStudio6)

Droplet digital PCR (BioRad QX200) - Biological Samples Description

Service	Type of sample	Type of organism	# of samples	# of runs per sample
Droplet digital PCR (BioRad QX200)

Proteomic Assays - Biological Samples Description

Service	Type of sample	Type of organism	# of samples	# of runs per sample
Proteomic Assays

Metabolomics - Biological Samples Description

Service	Type of sample	Type of organism	# of samples	# of runs per sample
Metabolomics

Other: ______ - Biological Samples Description

Service	Type of sample	Type of organism	# of samples	# of runs per sample
Other: ______

Please specify more details regarding the ______ service (s) requested:

* must provide value

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Description of SECC Services:

Consultation: A stand-alone meeting to gain insight and guidance regarding a writing project. Examples include discussion of grant or journal requirements and scope, orientation regarding a specific grammar or writing question, and organizing concepts in preparation for abstract/manuscript/grant writing.
Drafting: Assistance with generating a clean first draft of a short document to be sent for evaluation by author prior to submission (letters of support, letters of recommendation, media reports, etc.).
Editing: Evaluation of structure, logic, and alignment with target funding agency or journal's requirements; feedback regarding consistency, clarity, and grammar.
Translation: Translation of scientific documents (English-to-Spanish and Spanish-to-English) including informed consent forms, study surveys/questionnaires, investigator biographies, and public communications.
Training: Coordination of customized learning experiences for trainees, faculty, and staff to enhance core competencies in scientific writing and communication skills.

Select the service (s) you are requesting from the Scientific Editing and Communications Core

* must provide value

Consultation

Drafting

Editing

Translation

Training

Other

Other SECC Service:

* must provide value

Provide the URL of the RFA/journal guidelines you aim to submit. (if available)

Please attach the files you would like us to view as part of the service requested. If applicable or pertinent, include files such as research proposals, developed questionaries, granting agencies' RFAs, granting agencies' reporting requirements, among others.

Attachment number	Description	File upload
Attachment #1
Attachment #2
Attachment #3
Attachment #4
Attachment #5

For BBC, HTEL, PROMIC, PEC, Immuno, and Biobank services: Select a potential date or time for a preliminary meeting. Depending on the complexity of the requested service, the meeting can take 30 to 60 minutes. When selecting a date and time, please provide us with at least one (1) week to review the provided information (if applicable). Wait for appointment confirmation before attending the meeting.

* must provide value

M-D-Y

For SECC services: Select a potential date or time for a preliminary meeting. Depending on the complexity of the requested service, the meeting can take 30 to 60 minutes. Please select a date and time within 5 days of this request to facilitate streamlined services. Wait for appointment confirmation before attending the meeting.

* must provide value

M-D-Y

Select a potential time for the meeting:

* must provide value

H:M

Meeting preferences:

* must provide value

Preferred method of contact:

* must provide value

Expected service completion date:

* must provide value

M-D-Y

Please provide any other information you would like the core to have before evaluating your request.

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Provide the following information for billing purposes. A preliminary quote for the services requested will be provided after the initial meeting is held. An authorized representative will need to sign the quote before the service can be provided. All other services not included in the initial quote will be charged separately. Services will be charged after an invoice is provided and accepted by an authorized representative.

Provide the GL Account where the service (s) will be charged.

The maximum amount allocated for services provision purposes (if applicable).

For external members, services are charged at a standard fee. You can find the applicable rates at www.cccupr.com/sharedresoucesfees. A quote for the requested services will be provided after the initial meeting. All other services not included in the initial quote will be charged separately. A purchase order or contractual agreement must be in place before the service can be provided. A summary of Agreement conditions is described below:

1. Complete and provide the attached form with the bank or credit card information where services will be charged after the agreement.
2. Services will be charged quarterly after an invoice is provided and accepted by an authorized representative.
3. Services will be provided at the quoted rate unless both parties modify the agreement.

Additionally, provide the following information regarding the Institution and its Authorized Official who will sign the agreement. The Puerto Rico Government requires this information to draft and register the agreement.

Institution Legal Name (if applicable):

Institution Address:

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Name of Authorized Representative:

Marital Status of the Authorized Representative:

Municipality or State of Residence of the Authorized Representative:

Employers' Identification Number (EIN):

Does the Institution have other legal agreements with the UPRCCC or any other instrumentality of the Puerto Rico Government?

Yes

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List all other agreements your institution have with other Puerto Rico Government Instrumentalities.

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It is important that all services provided by any of the UPRCCC Shared Resources are acknowledged. If the collaboration matures, you should add a statement to your final publication similar to the following.

"The authors acknowledge the support received from [Facility Name (s)] of the University of Puerto Rico Comprehensive Cancer Center. The facility supported this work by providing [Add collaboration]. The content is solely the responsibility of the authors and does not necessarily represent the official views of the University of Puerto Rico Comprehensive Cancer Center."

By submitting this form, you acknowledge that an acknowledgment will be included in your final product stating that your work was carried out with the assistance of any of the Shared Resources of the UPRCCC.

Sign and Submit Form

* must provide value

Add signature

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