Principal Investigator Information

Name:

Email:

Department/Institution:

Mailing Address:

City:

State:

Zip:

Phone:

Fax:

Laboratory Shipping Address

Same as Principal Investigator

Name:

Email:

Department/Institution:

Mailing Address:

City:

State:

Zip:

Phone:

Fax:

Billing Address

Same as Shipping Address

Same as Principal Investigator

Name:

Email:

Department/Institution:

Mailing Address:

City:

State:

Zip:

Phone:

Fax:

Payment Information

FedEx Account #:

Account #:

P.O. #:

Credit Card

Study Information

Study Title:

Proposed Start Date:

IACUC#, IRB # or Expedited #:

Do you have sufficient funding for the acquistion of the requested samples?
Yes No

If yes, please specify source; If no, please provide details for securing funding

Approval Date:

Grant Number:

What is the purpose/scientific rationale?

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

What types of tissue and specific annotations are you requesting?

Justification of the number of specimens:

Details of study logistics:

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 IN-CANC-TissueBank@exchange.iu.edu of the publication. Thank you.

Donor criteria (optional)

Age:

Race:

Gender:

Diagnosis:

Support Documents

Samples Spreadsheet

PO Document

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.

Principal Investigator Information

Laboratory Shipping Address

Billing Address

Payment Information

Study Information

Donor criteria (optional)

Clinical Data - Check all that apply (optional)

Support Documents

Specimens List