Unveray Ot Rochester Medial Color 77 Pid Poche Now York 14623 ‘Sita Number 068 ‘Coararator Franelsco Mural investigator armen Serrano, MO v ROSTER ination Name (Ciicl Flesearch Consortium URMC LABS ‘SH.CP.CT jad.0224.0004 Kit Resupply Template Fass 1st FLAdults Universty Hospital ‘areas 2 PR Medical Center “Gly, Stato, Postal Code ‘San Juan, Puerto Pico 00836-0001 Phone, Fax 787 695 1190, 787 751 9911 SURE-PD3 Kit Re-Supply Form ‘Quantity Kit Name Date Needed By [ URMC Labs Internal Use Only T ‘Screening 1 Kit O€T OF 1 2O[F| IATA Visit Specitic Kit! I Screening 2 Kit O& 101 1 2014 |ATA Visit Specific Kit” 3 Multi-Visit Kit (includes Ambient Shippers) |_ OX 1 D/ | 2.014| \ATA Visit Specific Kit“ Buffy Coat (for DNA) Biomarker eT) Banding Callcton Me Buty Coat (for DNA) Gol lection it | L Plasma Biomarker Collection Kit O& 1 df | 2bI* | Piasma Biomarker. Collection Kit 24 hour Urine Collection Kit I t ‘24-hour Urine Collection: Kit Home Draw Urine Collection Kit t I ‘Urine Home Collection Kit Combo Coolers ‘ie Frozen Shippers: Urine Pregnancy Tests ai Urine Pregnancy Tests. Guantity| Additional Supplies Upon Project" |”. Date Needed. URMC Labs Internal Use Management Approval... Only oe t ! % : |. Quantity - Indicate how many of each item is needed. Sign and date bottom of this form. Please allow 7 to 10 business days for supplies to reach your sit Requestor Signature [Se © Date Needed By — Please provide a date supplies are needed. Do not write ASAP. Fax this form to URMC Labs at (585) 486-1375 or email LabSRSS@urme.rochester.edu Date DW -19- 201+ URMC Labs Use ONLY — Date Shipped URC Combo Boxes: Pillows Tatemational FedEx Pouches Bio-Hazard Stickers Gel Folds rg. Uline 7O.M. Shipping Boxes Dividers “Ambient Logo Boxes ‘Sm. Uline? O-M. Shipping Boxes: ‘Small Coolers Clinpak Bags Medium Coolers US FedEx Pouches Department of Pathology & Laboratory Medicine/Clinical Trials Central Laboratory Version date: 27May2015, Page 1 of 1