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4RTNI2 Blood Sample Form

Please complete this form when sending 4RTNI2 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.

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

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

( * = required field for submission )

General Information

Collection Information

Blood Processing

Plasma Processing

x 0.5mL

Serum Processing

x 0.5mL