PLEASE READ THE INFORMATION BELOW BEFORE COMPETING THIS FORM
The Principal Investigator (PI) responsible for overseeing the project and controlling the laboratory and personnel who will receive, use and process the requested specimens should complete this application. Any transfer of samples, aliquots, derivatives or associated clinical data to collaborating personnel or laboratories that are not under the direct supervision of the indicated PI requires the following:
A written justification of the need to transfer the materials and benefit to the applicant's research.
Copies of the
Agreement for Use of Tissue
Data Use Agreement
signed by the collaborator.
Documentation of the collaborator's IRB approval, exemption or documentation of IRB review unless the collaborator is covered under the IRB approval/review granted for the project proposed in this application.
The CHTN does not supply samples to specimen banks whose purpose is distribution to third-party researchers; those researchers should be encouraged to apply to the CHTN directly.
The information in this form is necessary in order to document correctly your request for tissue and other services and to ensure that the CHTN operates within the guidelines of the National Cancer Institute.
If requesting specimens from more than one specific anatomic site or disease, please complete separate copies of the Request Information Form (biospecimen, donor and preparation details) as necessary. Please be specific about your requirements, including those for storing and handling tissue samples from the time the specimens are collected until they are delivered to your lab (i.e. transport media, refrigeration status, etc.).
The CHTN maintains patient confidentiality. Samples and accompanying clinical data will be identified by a code, which will not be released under any circumstances.
The PI is responsible for remission of processing fees to the originating CHTN division for each specimen provided, including fees for any additional services performed and any shipping costs not directly billed to the applicant’s courier account. Please refer to the CHTN
for the current processing fees.
PIs must obtain human subjects review from their institution in order to receive specimens from the CHTN. Full or expedited approval or an exemption for your project can be obtained from your Institutional Review Board (IRB) (Human Use Committee). Documentation of annual review of non-exempt protocols by the PI’s institution must be forwarded to the CHTN in order to maintain eligibility to receive tissue. This is not necessary for exempt protocols. If your institution does not have internal review, contact your divisional coordinator.
Please provide a signed copy of the
Agreement for Use of Tissue
Data Use Agreement.
The language in both agreements is NOT to be altered.