Tissue Request Form Date MM slash DD slash YYYY Name and Title Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last Institution and Department Mailing Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhoneEmail Research ProjectIRB# and Complete Research Study Title Principal Investigator(s): Source of Funding (if any) Request for Tissue SamplesConcept SheetAbstractInclude a concise paragraph that summarizes the proposed study. Hypothesis Please be brief. Background & SignificanceState why this project is the next logical step in the development of this body of work. Comment on your ability to carry out this project.Research Plan & MethodsDiscuss experimental design and methodology. Be succinctStatistical ConsiderationsProvide statistical methods to be employed. Include power calculations and sample size. Research Category Cancer/Stem Cell Biology Research Radiation Biology & DNA Repair Research Immunology Research Clinical Trials Cancer Pharmacology/Experimental Therapeutics Biomedical Informatics & Biomedical Computation Research Genomics & Proteomics Research Biology, Oncogene & Cell Cycle Research Tissue Imaging Research Epidemiology IRB Approval LetterMax. file size: 125 MB.Attach a copy of your IRB approval letter to this request. No tissue will be released from the Florida Center for Brain Tumor Research Office until an approval letter is on file. Requested Tissue (select all that apply) Tumor Tissue Buffy Coat DNA Serum Plasma CSF Whole Blood Tumor Type Tumor Type cont.Please specify: Frozen, Fresh, or Fixed, the quantity and dimensions/mg of each tumor type you would like. Do you have any age limits? Sex Male Female No Selection Race White Black/African American Asian/Pacific Islander American Indian/Alaskan Native No Selection Ethhnicity Hispanic Non-Hispanic No Selection Consent FormConsent I agree to the policy outlined by FCBTR.Additional Specifications: Publication Policy It is understood and agreed that prompt publication of results of research conducted using Florida Center for Brain Tumor Research (FCBTR) resources is desired; and to that end, all Investigators shall be encouraged to publish results of such research in accordance with the publication policy of their institution. Subject to the acknowledgment requirement, each party shall be free to use the results of its research for its own non-commercial teaching, research, educational, clinical and publication purposes without the payment of royalties or other fees. Abstracts and manuscripts detailing results of studies utilizing samples from the FCBTR Brain Tumor Tissue Repository shall acknowledge the FCBTR as the source of the samples regardless of the FCBTR affiliation of the Investigators or authors. Prior to submission of the abstract or manuscript, each Investigator shall forward a copy to the Coordinator of the FCBTR for purposes of inclusion in the FCBTR Brain Tumor Tissue Repository Database and the FCBTR bibliography. Each Investigator shall provide one reprint of each published article involving tissue obtained from the FCBTR Tissue Repository to the Coordinator. Acknowledgment Policy If findings result in a publication, please include the following statement in the Acknowledgements or Methods section of your manuscript: “Tissue used in this project was provided by the Florida Center for Brain Tumor Research.” Human Subject Protection Policy In accordance with federal regulations, it is the responsibility of each Investigator to obtain appropriate approval from their local Institutional Review Board (IRB). No specimens will be released without an official approval letter on file in the FCBTR Office. Intended Use of Tissue Policy It is the policy of the Florida Center for Brain Tumor Research to limit the use of the tissue provided to you for that purpose for which it was explicitly requested. You must request permission in writing for any additional use. Confidentiality Agreement A University of Florida IRB Confidentiality Agreement form between FCBTR and the recipient Investigator must be completed and signed before tissue will be released. Investigator's signatureRequest Approved by(Please leave this field blank)Date Signed MM slash DD slash YYYY
