BBBSR Blood Sample Form

Please complete this form when sending BBBSR samples to NCRAD. The form can be submitted electronically or it may be printed and faxed.
If faxing the form, please do so as soon as possible after the sample is taken. NCRAD would like to receive this form before the sample arrives.

Fill out the form completely.
Click the 'Submit Form' button at the bottom of the page
Print a paper copy of the form to include with the physical sample when shipped

Print the static version of the form
Fill out the form by hand
Fax the form to Kelly Faber at (317) 278-1100 or email to alzstudy@iu.edu
Include the printed copy with the physical sample when shipped

( * = required field for submission )

General Information

From *

Date *

Phone *

Email *

UPS Tracking Number

Subject Information

Study *

GUID *

Visit *

Kit Number *

BBBSR ID *

Year of Birth *

Sex *

Blood Collection

Date Drawn *

Time of Draw *

Last date subject ate *

Last time subject ate *

Blood Processing

Plasma and Buffy Coat (Lavender-top) Tube (10mL)

EDTA #1 specimen number *

(Last four digits)

Original blood volume of EDTA #1 *

EDTA #2 specimen number *

(Last four digits)

Original blood volume of EDTA #2 *

Time spin started *

HHMM

Duration of centrifuge *

mins

Temp of centrifuge *

°C

Rate of centrifuge *

x g

Time aliquoted *

HHMM

Number of 1.5 mL plasma aliquots created *

(purple cap, up to 6)

If applicable, volume of residual plasma aliquot

(less than 1.5 mL in blue cap)

If applicable, specimen number of residual plasma aliquot

(Last four digits)

Buffy coat #1 specimen number *

(Last four digits)

Buffy coat #1 volume *

Buffy coat #2 specimen number *

(Last four digits)

Buffy coat #2 volume *

Time aliquots placed in freezer *

HHMM

Storage temperature of freezer *

°C

BBBSR Blood Sample Form

Instructions for Electronic Submittal

Instructions for Fax/Email Submittal

General Information

Subject Information

Blood Collection

Blood Processing

Plasma and Buffy Coat (Lavender-top) Tube (10mL)

Notes