Request for Biobank samples and data from SSBCG

1. Responsible researcher
Name / Research location
Address
E-mail / Phone
2. Ethical clearance
Granted / Date of approval from Ethics Committee / Ethics Committee approval number
An application will be/has been sent to the Ethics Committee
3. Project description
New application or Supplement to a previous application (please provide application number)
Number of samples requested Type of sample requested (tissue, lysate, etc)
Project title
4. Requested data
Specify type of data required:
Personal ID numbers or e.g. PAD numbers
Biobank numbers (i.e. Ca numbers)
Project specific identification numbers sufficient
If personal data are required, please specify:
5. Attachments (Please See “Application for Access to Frozen Tissue” instructions for further details)
Att. 1. Written description of the research project, including specification of sample type (tissue, cytosol, pellet, DNA, RNA), amount per sample, and total number of samples.
Att. 2.Copy of Ethics Committeeapplication and approval.
Att. 3.List of samples and amounts requested.
6. Cost of sample retrieval and data management(Please see section9, note 5)
I am aware that a fee will be charged in order to cover sample retrieval and data management
Yes
Invoice address including‘kostnadsställe’ and reference:
7. Signatures (I have read and acknowledge the Terms under section 9)
Date and signature by applicant / Date and signature by principal investigator, where pertinent
Name in block letters / Name in block letters
8. SSBCG Biobank Steering Committee decisions
Application approved Yes No
Special Instructions:
Starting fee (SEK): + OH
Price per hour (SEK): +OH
Date and signature by authorized representative of SSBCG / Name in block letters
Release of samples approved Yes No
Special Instructions:
Date and signature by authorized representative of SSBCG / Name in block letters
9. Terms and conditions for transfer of samples and related information
1. The following general terms and conditions prevail between applicants/fellow applicants (jointly referred to as “applicants” below) and The SSBCG Biobank Steering Committee for transfer of samples and information from the Biobank.
2. In signing, the applicants acknowledge that they agree to and accept the following conditions for transfer of samples and information from the Biobank. The term ”information” includes data collected at the time of specimen collection as well as information acquired by the Biobank thereafter. The applicants may use the samples and information only for the purposes specifiedin the description of the research project.
3.a)Samples and information will be released for analysis under code. The applicants agree to return a progress report to The SSBCG Biobank Steering Committee within one year of sample release according to the Application for Access to Frozen Tissue instructions, as well as a final report outlining analyses performed and publications or other output upon completion of the project.
b)Results obtained based on samples/information from the Biobank remain the property of the applicant, but may be used by The SSBCG Biobank Steering Committee or by future applicants uponpermission of the depositor. Only if and when the depositor so wishes these results may become the property of the Steering Committee; such an agreement may be included in the decision of The SSBCG Biobank Steering Committee.
c)As amounts of biological samples are limited, all requests for samples must include a justificationfor the amount of sample requested. Requests for excessive amounts will be negotiated prior to release.
d)The use of samples or information in research conducted in cooperation with, under the assignment of, under the license of, or under similar conditions in connection with, a commercial company is forbidden unless prior written approval (i.e. Material Transfer Agreement) has been obtained from The SSBCG Biobank Steering Committee.
e)The applicant agrees to return any unused portion of samples, including extracted DNA, RNA and protein, as soon as the research project has been completed. Following contact with The SSBCG Biobank Steering Committee, small portions may instead be destroyed.
f)The applicants agree not to transfer samples or information to third parties other than those specified as laboratories performing analysis of the samples in the description of the research project.
4. Additional samples or information from the research subjects, or their relatives, to which received samples or information are connected, may not be acquired without special permission from The SSBCG Biobank Steering Committee.
5. The applicant will be charged for costs related to retrieval of samples and information. These costs cover sample and data retrieval, aliquoting, maintenance of the Biobank, and data management. The receiver of samples will also bear anycost of handling and transport (including returned samples) in addition to the costs above.
6. Projects leading to potential patent applications must comply with Region Skåne (Southern Healthcare Region) regulations (please see for further details), and should be reported to The SSBCG Biobank Steering Committee immediately.
7. The applicants are forbidden to transfer their rights or obligations according to this contract to third parties without prior written approval from The SSBCG Biobank Steering Committee.
8. All approved projects must be reported back to The SSBCG Biobank Steering Committee. A progress report is requested within 12 months after release of samples. A final report (upon completion of the project) should include information about analyses performed, results, publication/s and/or other outputs.The South Swedish Breast Cancer Group (SSBCG) Biobank must be acknowledged in all publications based on samples from the biobank.
9. This contract falls under Swedish law. Conflicts arising from this contract will be settled in Swedish court.
11.General Information
This request form should be sent as:
1) Electronic copy, and
2) Signed hardcopy
To:
Ingrid Hedenfalk
Lund University Cancer Center/Medicon Village
Div of Oncology and Pathology
Dept of Clinical Sciences and
Skåne University Hospital
SE-223 81 Lund, Sweden
E-mail: / Contact information:
IngridHedenfalk
Lund University Cancer Center/Medicon Village
Div of Oncology and Pathology, Dept of Clinical Sciences
SE-223 81 Lund, Sweden
E-mail:
Phone: 046-2220652
SSBCG Steering Committee 2015 / Page 1 of 2
The South Swedish Breast Cancer Group (SSBCG) Biobank
Version date: 10/9/2015