Principal Investigator Information

Laboratory Shipping Address

 Same as Principal Investigator

Billing Address

 Same as Shipping Address
 Same as Principal Investigator

Payment Information


Study Information

Do you have sufficient funding for the acquistion of the requested samples?

Please provide a brief summary of the data/research that supports your hypothesis.

Outline the details of your study logistics and methodology and what tests and analysis you will be conducting on the sample.

PUBLICATION ACKNOWLEDGEMENT: If research supported by the IUSCC Tissue Procurement and Distribution Core results in publication, please acknowledge this support by including the following in your publication(s):

We thank the IUSCC Cancer Center at Indiana University School of Medicine funded by the IU Simon Cancer Center Support Grant P30 CA082709, for the use of the Tissue Procurement and Distribution Core, which provided __________ service.

Please notify the IUSCC Tissue Procurement and Distribution Core at of the publication. Thank you.

Donor criteria (optional)

Clinical Data - Check all that apply (optional)

No Additional Fees

 Donor Demographic information(e.g. age,sex,vital signs)
 Histology and diagnosis details (e.g. histologic type,stage,grade)
 Surgery (e.g. procedure types and dates)
 Sample collection details

Additional chart review fees may apply

 Radiotherapy (e.g. intent,start and end dates,dose)
 Systemic therapy (e.g. intent, start and end dates, regimen and agent details)
 Family history of cancer
 Toxicities relating to treatment
 Patient History (e.g. prior cancers, history of smoking, risk factors)
 Outcome / Follow-up (e.g. progression/recurrence status, disease-free period)

Support Documents

Specimens List

 I have completed IU or other approved Biosafety Training on handling human tissue and blood.
 I have passed the Human Subjects Protection Course.
 I have received at least 2 inoculations in the vaccination series for Hepatitis B.

Documentation for completion of the above requirements is not required at this time but may be required
in the future.