Manitoba Tumour Bank
Bio-Specimen Application Form
Study Title
Principal Investigator Information
SalutationGiven NameMiddle NameSurname
Department and Institution
Street AddressCityProvince Postal Code
Office Phone #Lab Phone #Fax #Email
Laboratory Shipping Information
Name of Shipping Contact Department and Institution
Street AddressCityProvince Postal Code
Telephone #Fax #Email
Fed Ex or Preferred Courier and Account Number #
Application date:
- Details of Bio-specimens and Data Requested
TISSUE SECTIONS
Disease Site(s):
BreastHead & NeckLung Ovarian Prostate
# of Cases
Samples:
# of sections # of sections Thickness
on slides in tubes (in um)
FFPE
Frozen
Matched normal tissue required Normal tissue may be unmatched
INTENDED USE OF BIO-SPECIMENS
Please select all intended applications IHC ISH PCR RT-PCR Western
Other specimen requirements
CLINCAL DATA REQUIREMENTS
NOTES ON DATA REQUIREMENTS
Composition data (%tumor, %normal, etc.):
Pathology data (tumor type, grade, etc.):
Treatment data (chemo, radiation, etc.):
Outcome data (follow-up status, etc.):
Other data;
BLOODPRODUCTS
DISEASE SITE(S):
AML/ALL CLL Head & Neck Lung MMY Ovarian Prostate
# of Cases
BLOOD SAMPLE TYPE:BLOOD CELLS:
Yes No Amount per Sample:
Plasma 1.0ml/Vial Cell Culture (Cryo)5x106
Plasma (CLL Only) 1.8ml/VialCell Pellet (DNA) 1x108
Buffy Coat RNALater 1x108
BONE MARROW
DISEASE SITE(S): SAMPLE TYPE:
AMLCLLMMY Amount per Sample:
# of Cases Cell Culture (Cryo) 5x106
Plasma 1.8ml/Vial
INTENDED USE OF BIO-SPECIMENS
Please select all intended applications IHC ISH PCR RT-PCR Western
Other specimen requirements
CLINICAL DATA REQUIREMENTS
NOTES ON DATA REQUIREMENTS
Clinical Parameters (Rai Stage, Zap 70, etc.):
Treatment data (chemo, radiation, etc.):
Outcome data (follow-up status, etc.):
Other data;
URINE
DISEASE SITE: Prostate OnlyURINE SAMPLE TYPE:
Amount per Sample
# of Cases: Supernatant 1.0ml
Pellet1.0ml
FTA CARD (Buccal Swab)
DISEASE SITE(S): SAMPLE TYPE: Amount per Sample
AML /ALL CLL MMY Buccal Swab/FTA Card 4 Punches/Card
# of Cases
INTENDED USE OF BIO-SPECIMENS
Please select all intended applications IHC ISH PCR RT-PCR Western
Other specimen requirements
CLINICAL DATA REQUIREMENTS
NOTES ON DATA REQUIREMENTS
Diagnosis Data (Diagnosis, stage, etc.):
Treatment data (chemo, radiation, etc.):
Outcome data (follow-up status, etc.):
Other data;
B. Other Application Details
B.1 Timeframe samples are required in (please select one):4-6 weeks 6-10 weeks
B.2 Has/Is/Will this specific project receive independent scientific/methodological peer review?
If yes, please indicate the names of the agency, committee or individual and review dates:
If not, please justify or explain why no review has taken place:
B.3 Has this project been approved by your REB/IRB:Yes No
(If this application is successful a copy of the REB/IRB approval certificate will be required prior to release of samples)
B.4 Have you secured funding to carry out this project?Yes No
(If this application is successful a copy of the granting/funding agency approval letter will be required prior to release of samples)
If yes, please name the funding source (agency, project title, monies, and dates):
If not, please explain how funding will be obtained:
Required supporting documentation:
1. A current curriculum vitae for the Principal Investigator(any agency CV is accepted, e.g. Common CV, NCIC, DOD, NIH, MSFHR, etc.)
2. A one-page summary/abstract of the research project – please paste into box on page 7.(Include hypothesis, aims, technical approach & statistical justification for required sample size)
Summary/Abstract of the research project:
1
MTB Bio-Specimen Application Form July 2015