If your lab is receiving material for use in a clinical trial, please fill out this form.
* indicates required fields.
Principal Investigator *
SU Lab Contact/Admin Name & E-mail *
Provider Institution/Company Name *
Provider Contact Name & E-mail *
Describe the drug or device:
Will the Material be used in a clinical trial at Stanford with one or more other drugs/devices? If so, please provide the SPO # for the clinical trial:
Please provide IRB protocol #(s) : *
Upload IRB approval/exemption letter below:
Human stem cells, embryos, or oocytes (SCRO)
Radiologically hazardous (CRA/SMN)
Obtained from a living person (IRB)
Infectious or Biohazardous not including Viral Vectors (APB)
rDNA non-exempt under NIH guidelines (APB)
Check box to confirm
Please provide protocol #(s) for the above selection(s) :
Who developed the Protocol?
Who is the Sponsor of the trial?
Industrial Affiliates Program
Federal contract(s) or grant(s)
Name the above funding source(s) for your trial:
Advisory Board Member or Board of Directors
Ownership of stock or stock options
Attach the Word version of the agreement, if available. Do not have the PI sign the agreement until it has been reviewed by ICO:
Your E-mail *
After you click “Submit Form” below, you will receive an e-mail confirmation. We will contact the Principal Investigator and individual(s) identified as the Lab Contact/Admin about next steps. For questions, please contact: email@example.com
Please skip. Do not fill this out.