SECTION1:Request-Tobecompletedbypi

SECTION1:Request-tobecompletedbyPI

1. PrincipalInvestigator:Click here to enter text.

1. Project Title:Click here to enter text.

1. ProjectDescription:(briefdescriptionofprojectincludingwhyyouarerequestingsamples,includeifyouhavedonethisworkincelllines)

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1. AreyouamemberoftheCancerCenter?: Choose an item.

1. Ifthereisapeer-reviewedprojectforwhichthesesampleswillbeutilized,pleaseprovidethefollowing:

GrantName:Click here to enter text.

Sponsor:Click here to enter text.

PI:Click here to enter text.

Datefundingbegins/began/planningtosubmit:Click here to enter a date.

Datefundingends:Click here to enter a date.

1. Numberofsamplesrequested:Click here to enter text.

1. Sample Requirements: select all that apply

Diagnosis Category: / ☐ / ALL, B-Cell
☐ / ALL, T-cell
☐ / AML
☐ / CLL
☐ / CML
☐ / Lymphoma
☐ / MDS/myeloproliferative disorders
☐ / Multiple myeloma
☐ / Other, describe: Click here to enter text.
Disease Status: / ☐ / Original diagnosis
☐ / Original diagnosis - refractory
☐ / Original diagnosis - on therapy (tx)
☐ / Relapse
☐ / Relapse - refractory
☐ / Relapse - on therapy (tx)
☐ / Post stem cell transplant (SCT)
☐ / Off therapy (tx)
Are you interested in paired samples from a patient? / ☐ / Diagnosis/relapse
☐ / Diagnosis/post transplant
☐ / Blood and bone marrow collected at the same time
☐ / Other, describe: Click here to enter text.
Age: / ☐ / Adult
☐ / Pediatric
Source of Cells: / ☐ / Peripheral blood
☐ / Bone marrow
☐ / Peripheral blood or bone marrow
Sample Type: / ☐ / Mononuclear cells, viable
☐ / Non-viable cells for DNA isolation (contains mostly granuolocytes)
☐ / Non-viable cells for DNA isolation (whole blood or marrow)
☐ / Plasma
Blast count (prior to process and freeze): / ☐ / 0-25%
☐ / 26-50%
☐ / 51-75%
☐ / 76-100%

1. OtherSubject/SampleRequirements: Click here to enter text.

1. MultipleSample Aliquots: Onealiquotpersamplewillbeapprovedandreleased.Requestsformultiplesamplealiquotsand/orreleaseofadditionalaliquotsaresubjecttopreliminarydatareviewandapprovalbytheHMTB.Describebelowifrequestingmultiplealiquots.Click here to enter text.

NOTE:

1. PImustsubmitacopyoftheIRBAPPLICATIONorIRBAPPROVALletterwiththisapplication.SamplescannotbereleaseduntilIRBapprovalhasbeenreceived.

1. TheHeme MalignancyTissueBankshouldbeacknowledged on any grant application or publicationthatisbasedonsamplesreceived.

PIElectronicSignature: Click here to enter text.

Bytyping yourname above,you certify that this isyourelectronicsignature.

Date:Click here to enter a date.

Pleaseemailto:

SECTION 2: Review - To be completed by the HMTBDirector

1.Evaluatetheprojectforscientificmerit,peer-review,CancerCentermembership,etc.:

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2.Dowehavesamplesofinterest?:Click here to enter text.

3.Ifwehavesamplesofinterest,howmanysamplesandhowmanyaliquotspersample?:

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4.Arethereadditionalcriteriaforreview?:

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5.Sampleidentificationto bereleased(ifapproved):

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☐ / Approve
☐ / Deny

6.

HMTBDirectorElectronicSignature: Click here to enter text.

Bytyping yourname above,you certify that this isyourelectronicsignature.

Date: Click here to enter a date.

Pleaseemailto:

SECTION 3: Release - To be completed by the TTL Coordinator and Staff

1.IRB#:Click here to enter text.

2.IRBapprovaldate: Click here to enter a date.

3.TTL Coordinator recommendations/planfor PI:

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TTL CoordinatorElectronicSignature: Click here to enter text.

Bytyping yourname above,you certify that this isyourelectronicsignature.

Date: Click here to enter a date.

Samplesreleasedto:Click here to enter text.

TTL StaffElectronicSignature: Click here to enter text.

Bytyping yourname above,you certify that this isyourelectronicsignature.

Date: Click here to enter a date.

Pleaseemailto:

Version: 12.12.2016Page 1 of 5