Institutional BioRepository / מאגר דגימות מוסדי לצורכי מחקר
Specimens Request Form
1. Tissue type:2. Principal Investigator:
3. Collaborators (including Institution &Department)
4. Project title:
5. Primary study objective(s):
6. Brief justification (Describe the innovation and contribution of the study to scientific knowledge and possible applicator– include top 3-5 references):
7. Preliminary data (Maximum one page):
8. Statistical considerations, including sample size and proposed analyses:
9. Human tissue specimens requested:
a. Type of disease/tumor:
b. Please indicate preferred Gender: ☐Female /☐ Male / ☐Either
c. Will you accept tissue from patients previously treated with:
Radiation? ☐Yes / ☐No
Chemotherapy?☐ Yes / ☐No
d. Must specimen be sterile? ☐Yes / ☐No /☐As clean as possible
e. Patient Limitations (i.e. age, race, or other limiting characteristics):
f. Please indicate amount and type of biological material needed in the table below.
Type # / Amount #
☐ / Frozen tissue (Malignant & Normal) / Malignant: ☐
Normal: ☐ / Malignant vials #:
normal vials #:
(per sample)
If malignant is selected, please specify if matched normal tissue from the same patient required? / ☐Yes / ☐ No /
☐If available
☐ / Frozen serum (-80°C) / Patients #: / Volume per sample: µl
☐ / Frozen plasma (-80°C) / Patients #: / Volume per sample: µl
☐ / Frozen peripheral lymphocytes (-195°C) / Patients #: / Vials per sample:
☐ / Paraffin-embedded tissue / Patients #:
Total number of samples
10. Duration of the proposed study:
11. Schedule to acquire the specimens (i.e., all at one time, batched at specific time intervals, etc):
12. IRB-approved protocol information (Note: tissues will not be released without an IRB-approved
protocol in place. Please provide a copy of protocol and IRB approval letter).
a. Application #:
b. Approval Date:
c. Validity Date
13. State the study’s source of Funding? (fund, governmental, existing funds, private corporation, collaboration with industry, other)
If yes:
a. Name of sponsor
b. Name of project
c. Is this project part of a grant or sponsor already supporting the biobank activities?
- If yes, briefly describe
- If not currently funded, provide information on other sources of potential funding
14. Additional Comments
15. State if the principal investigator/company have received samples from any Israeli Biorepository.
16. State if the principal investigator’s department received samples from the Biorepository
Contact person:
רח' וייצמן 6, ת"א 64239 טל' 03-6947561 פקס 03-6973610 דאר אלקטרוני