HSA Biobank Specimen/Data Form

HSA Biobank Specimen/Data Form

Please complete all sections if you are requesting specimen and health data for your project. However, for specimen only applications complete sections A B C F; and for data only applications complete sections A B D.

Section A: Project and Contact Details

1.Project title

Click here to enter Project Title

2.Contact details – Principal Investigator

Title & Name / Title Click here to enter name
Position / Click here to enter Position /
Department / Click here to enter Department /
Institution / Click here to enter Institution /
Email / Click here to enter email address /

3.Contact Person for Enquiries (if different to Principle Investigator)

4.Description of studybackground (including preliminary data) (max. 500 characters)

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5.Aims and hypothesis (max. 200 characters)

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6.Methods(please include a justification for number and type of tissue requested, and whether this is a standalone project or part of a larger project pooling with other samples/data)(max. 500 characters)

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7.Experimental techniques proposed

Immunohistochemistry (IHC)

Rt-PCR

Other (Please explain: )

8. ForIHC techniques: Have the primary antibodies been optimized on similar FFPE sections*, to reduce wastage of the HSA Biobank tissue samples?

*Pleasegive evidence of antibody optimization(including images where relevant) with your application

(max. 200 characters)

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9.Project timeline

Start Date / Click to enter date / Completion Date* / Click to enter date /

*Time estimated to finish the analysis (before submitting for publication)

10.Return of data and/or excess samples

Would you be willing to be contacted by other researchers about data you have generated on these samples? (with the understanding that you have published results and necessary approvals are in place for data sharing)

☐ Yes

☐ No

Does this request include excess material to allow for repeats? If yes, we ask that you return excess samples for the benefit of other researchers.

☐ Yes

☐ No

Section B: Ethics Approval Information

Has HREC approval been obtained for this project? Choose an item.

(date of application if pending: Click to enter date)

Please attached a copy of your ethics application and approval letter, when available, with this application

2.De-identified health data

Please note: data can only be released if appropriate ethics approval has been obtained to access such data

Does your ethics application request approval for access to de-identified health data? Choose an item.

3.Ethics applications(Specimens will not be released until Ethics approval has been received)

Primary ethics approval for project:

/ Status of application:
☐Approved (attach approval letter)
Date approved: Click to enter date
☐Not approved, revisions in process
☐Not yet submitted

Additional approvals (where applicable):

/ Status of application:
☐Approved (attach approval letter)
Date approved: Click to enter date
☐Not approved, revisions in process
☐Not yet submitted

Section C: Tissue Details

Tumourtype (e.g. sarcoma) / Tissue type (e.g. FFPE, Plasma, etc) / Quantity per case (e.g. slides, µg, etc) / Number of cases / Date required by
Click to enter text / Click to enter text / Click to enter text / Click to enter text / Click to enter date /

Please add more rows as required by selectingany cell in the last row and clicking on the symbol to the right

Please include any other specific requirements/details for your project below

Click or tap here to enter text. /

Section D: Data Checklist

It is important that you select only variables necessary for your project.

Also, PLEASE NOTE not all variables may be available for all participants at the time of request.

Data Specifications – please provide as much information as possible to assist with data extraction

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HSA Biobank | UNSW Biorepository | UNSW Sydney NSW 2052

E: | T: +61 2 9382 8853

HSA Biobank research application form_V1.3

1.Core Data Items

☐ / Age at diagnosis
☐ / Gender
☐ / Clinical diagnosis
☐ / Tumour tissue site
☐ / Tumour tissue pathological status
☐ / De-identified anatomical pathology report

2.Clinical information of primary cancer diagnoses

☐ / Tumour site ICD-10
☐ / Tumour morphology ICD-O-3
☐ / Tumour stage
☐ / Tumour grade
☐ / Basis of diagnosis
☐ / Chemotherapy treatment date, protocol, number of cycles
☐ / Radiotherapy treatment date, type, dose, number of fractions
☐ / Date of death

3.Pharmaceutical Benefits Scheme (PBS)*

☐ / Date of supply
☐ / Date of prescribing
☐ / PBS item code
☐ / PBS item description
☐ / Patient category
☐ / Patient contribution
☐ / Net benefit
☐ / Anatomical Therapeutic Chemical (ATC) Code

4.Medicare Benefits Scheme (MBS)*

☐ / Date of service
☐ / MBS item number
☐ / MBS item description
☐ / Item category
☐ / Provider charge
☐ / Schedule fee
☐ / Benefit paid
☐ / Date of referral
☐ / Scrambled ordering provider number
☐ / Scrambled rendering provider number
☐ / Hospital indicator

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HSA Biobank | UNSW Biorepository | UNSW Sydney NSW 2052

E: | T: +61 2 9382 8853

HSA Biobank research application form_V1.3

* MBS and PBS data from November 2009 onwards. Use and rationale for these data sources must have been stated in your ethics application before data will be released.

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HSA Biobank | UNSW Biorepository | UNSW Sydney NSW 2052

E: | T: +61 2 9382 8853

HSA Biobank research application form_V1.3

5.Other data specifications

Please list any other data specifications for your project. Please note these may not be available at the time of request

Click here to enter text

Section E: ACKNOWLEDGEMENT

By accessing specimens and/or data, you agree to acknowledge the HSA Biobank in any publications arising from the use of specimens and data provided by using the following text.

Biospecimens and data used in this research were obtained from the HSA Biobank, UNSW Biorepository, UNSW Sydney, Australia

We also ask for all publications resulting from samples and/or data tobe reported to the HSA Biobank. The HSA Biobank Project Manager will contact you periodically to report on research output.

Section F: SPECIMEN TRANSFER

Please provide contact details for person receiving specimens.

Will the specimens be transferred to another location, other than UNSW, for this project? Choose an item.

Title & Name / Title Click here to enter name
Institution / Click here to enter Institution /
Address / Click or tap here to enter address /
Email / Click here to enter email address /

Please ensure all relevant sections have been completed in full as any incorrect applications

may bereturned to you for amendments which could result in delays.

This runs on cost-recovery, you will be sent a quote after approval.

Allow 28 working days for processing of application.

Submit the completed application form via email to:

Office Use ONLY

To be completed by RESEARCH ACCESS COMMITTEE:

Do you recommend that this request for biospecimens / data be approved?

☐ / Yes (provide comments below – optional)
Click here to enter text
☐ / Yes - subject to modification(please include suggested changes and rationale for these)
Click here to enter text
☐ / No(please provide reasons)
Click here to enter text

Application approved by: Date:

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HSA Biobank | Lowy Cancer Reseach Centre | UNSW Sydney NSW 2052

E: | T: +61 2 9382 8853