ALLG Discovery Centre
Princess Alexandra Hospital
c/- Haematology/Pathology
Main Building Level 1
Ipswich Road
Woolloongabba
QLD 4102
www.allg.org.au
Improving the treatment and the lives of patients with blood cancers through clinical trial research
ALLG Leukaemia and Lymphoma Discovery Centre
Biobanking for blood cancer
Appendix B Application for Tissue Samples
1. INVESTIGATOR INFORMATION
Investigator name:
(include title)
Investigator contact
details
Current position or
appointment:
Institution:
Address:
Email:
Telephone:
Investigator CV. Please insert a short CV which includes your professional education, research
and professional experience and peer-reviewed publications published in the last 5 years.
2. TISSUE SAMPLE REQUEST
Have you contacted the ALLG Discovery Centre staff to confirm sample numbers for your project
are available?
Yes
No. Please contact Megan Ellis, ALLG Tissue Bank Manager
Ph: (07) 3176 5835
Email: megan_ellis@health.qld.gov.au
Describe the samples you are requesting from the ALLG Discovery Centre. Add more boxes as
required.
Sample request 1.
WHO Classification:
Tissue source:
Sample type: (RNA,
DNA, serum etc.)
1
ALLG Discovery Centre
Princess Alexandra Hospital
c/- Haematology/Pathology
Main Building Level 1
Ipswich Road
Woolloongabba
QLD 4102
www.allg.org.au
Improving the treatment and the lives of patients with blood cancers through clinical trial research
Volume:
Quantity:
Please provide
sample number
calculations to justify
the number of
samples requested (if
applicable).
Sample request 2.
WHO Classification:
Tissue source:
Sample type: (RNA,
DNA, serum etc.)
Volume:
Quantity:
Please provide
sample number
calculations to justify
the number of
samples requested (if
applicable).
Sample request 3.
WHO Classification:
Tissue source:
Sample type: (RNA,
DNA, serum etc.)
Volume:
Quantity:
Please provide
sample number
calculations to justify
the number of
samples requested (if
applicable).
Sample request 4.
WHO Classification:
Tissue source:
Sample type: (RNA,
DNA, serum etc.)
2
ALLG Discovery Centre
Princess Alexandra Hospital
c/- Haematology/Pathology
Main Building Level 1
Ipswich Road
Woolloongabba
QLD 4102
www.allg.org.au
Improving the treatment and the lives of patients with blood cancers through clinical trial research
Volume:
Quantity:
Please provide
sample number
calculations to justify
the number of
samples requested (if
applicable).
3. REQUESTS TO OTHER TISSUE and BIO BANKS
The ALLG Discovery Centre receives samples from numerous Australian institutions. To prevent
issue of duplicate samples, we ask investigators to disclose requests to other Bio Banks for this
project.
Have you applied or will you be applying for samples from any other Tissue or Bio Banks for this
project?
Yes (provide details below)
No
Tissue Bank name:
Samples requested:
Tissue Bank name:
Samples requested:
Tissue Bank name:
Samples requested:
4. SAMPLE LOGISTICS
Sample delivery
information
Name of contact
person for delivery:
Contact person
phone number:
Days of week and
hours of operation
available for courier
delivery:
Exact delivery
address to be used
by courier:
3
ALLG Discovery Centre
Princess Alexandra Hospital
c/- Haematology/Pathology
Main Building Level 1
Ipswich Road
Woolloongabba
QLD 4102
www.allg.org.au
Improving the treatment and the lives of patients with blood cancers through clinical trial research
Would you like the
ALLG to organise
sample transport on
your behalf?
Yes
(ALLG will organise dispatch, initially pay courier
costs and then invoice researcher for
reimbursement of the transport costs when
invoicing for sample cost recovery)
No
(The organisation and cost of sample transport will
be the responsibility of the researcher. Confirmation
of dispatch dates with ALLG staff must be
organised by the researcher prior to booking
couriers)
5. PROJECT INFORMATION
Project details
Title of proposed
project:
Anticipated project
commencement
date:
Anticipated project
completion date:
Location where
project will be
undertaken:
Approvals
Funding status of
the project
Do you have
Institutional support
to undertake this
project?
Yes (ensure Section 7 is completed)
No – Institutional support is required for
issue of samples of the Discovery Centre
Do you have Ethics
Committee approval
to undertake this
project?
Yes (attach Ethics Committee approval letter)
No – Ethics Committee approval is required
for issue of samples
What is the funding
status of this project?
Provide details of
any secured or
pending funding for
this project:
Fully funded
Pending grant application
NHMRC grant Application ID: _________
other grant*
internal funding/grant*
other*
*Provide details below
Please attach approval letter(s) for secured
funding/grant(s) for this project.
4
ALLG Discovery Centre
Princess Alexandra Hospital
c/- Haematology/Pathology
Main Building Level 1
Ipswich Road
Woolloongabba
QLD 4102
www.allg.org.au
Improving the treatment and the lives of patients with blood cancers through clinical trial research
Funding details and
comments:
Project description. Please provide a description of the project that will be undertaken. Include
background, rationale, methods and references.
5
ALLG Discovery Centre
Princess Alexandra Hospital
c/- Haematology/Pathology
Main Building Level 1
Ipswich Road
Woolloongabba
QLD 4102
www.allg.org.au
Improving the treatment and the lives of patients with blood cancers through clinical trial research
6. CONDITIONS OF USE OF TISSUE BANK SAMPLES Appendix C
Please read the following information and complete Section 7.
Samples from the ALLG Discovery Centre are provided with the intention of facilitating research
into haematologic malignancies. The samples must be used in the manner described in this
application. Any change in the project direction must be communicated in writing to the ALLG
Discovery Centre Manager and Director which reserves the right to withdraw support. Samples
must not be given or sold to other investigators.
The samples provided to researchers are de-identified. No attempts should be made by the
Investigator to identify the patient or to determine other patient information. If additional information
is required, it should be requested through the Discovery Centre Manager who will forward the
request to the relevant ALLG committee. Clinical data can be retrieved from the ALLG trial centre
when pertinent to the interpretation of the research. There may be a charge associated with the
retrieval of clinical data.
The tissue provided is as far as possible representative of the entity requested. However,
diagnostic verification has not been undertaken in all cases. The ALLG accept no responsibility for
the inadvertent provision of incorrect tissue. In addition, while every effort is made to provide high
quality material, sample transport prior to storage is an uncontrolled variable which may interfere
with sample quality. Although every attempt is made to preserve the quality of the samples, the
ALLG cannot guarantee that mRNA will be obtained from samples.
While samples are not stored from patients with known HIV, Hepatitis B or Hepatitis C, the
screening of patients for the presence of such pathogens is not routine. Standard precautions for
the handling of human tissue and fluid as recommended by the Australian National Health and
Medical Research Council (NHMRC) should be used in all cases to prevent infection with any
pathogens present. No responsibility will be taken by the ALLG for injury or illness that may occur
to staff handling the samples.
There may be a cost recovery charge for the provision of specimens depending on funding
arrangements. The costs of packaging and transport of the specimens will be borne by the
individual requesting the samples.
The Investigator(s) is required to provide a 12 month report which summarises the progress of the
research and outlines the use and usefulness of the supplied samples, whether the study is
ongoing and the anticipated date of study completion. This is to be submitted by the end of
December. You will not be asked to reveal the results of the study in this report. At study
completion, any remaining samples should be returned for use by others.
Depending upon the level of contribution of the ALLG to the project, the Investigator will be
required to either
(i) acknowledge the ALLG in any publications or presentations resulting from the work; or
(ii) enter into collaboration with the appropriate ALLG member(s) who will be recognised as a
co-author on any publications resulting from the work.
The type of recognition required will be decided on a case by case basis at the time of application
approval and throughout the project. Failure to recognise the ALLG in the manner decided by the
Committee will render the individual and/or the institution ineligible for future applications.
6
ALLG Discovery Centre
Princess Alexandra Hospital
c/- Haematology/Pathology
Main Building Level 1
Ipswich Road
Woolloongabba
QLD 4102
www.allg.org.au
Improving the treatment and the lives of patients with blood cancers through clinical trial research
Copies of any publications arising from the use of ALLG Discovery Centre samples should be
forwarded to the Discovery Centre Manager who will then notify the relevant ALLG committee.
Samples will not be provided until a signed copy of the Agreement (Section 7 below) has
been received.
7
ALLG Discovery Centre
Princess Alexandra Hospital
c/- Haematology/Pathology
Main Building Level 1
Ipswich Road
Woolloongabba
QLD 4102
www.allg.org.au
Improving the treatment and the lives of patients with blood cancers through clinical trial research
7. AGREEMENT FOR ALLG DISCOVERY CENTRE SAMPLE USE Appendix D
I, ____________________________________ (print name) have read, understood, and agree
with the ‘Conditions of Use of ALLG Discovery Centre Samples’ (Section 6 above).
I additionally agree to the following:
1.
2.
3.
4.
5.
6.
That I will use the specimens provided to me by the Discovery Centre only in the manner
detailed in my application for these specimens. I will not give or sell them to a third party or
use them for any purpose not specified in the application without prior specific approval.
That I will not, in any way, attempt to identify the patients from whom these samples were
obtained, nor will I attempt to gain any personal information regarding these patients other
than that obtained through the Discovery Centre. Clinical information pertaining to these
patients and pertinent for my research may be requested through the ALLG Discovery
Centre Manager where the request will be forwarded to the relevant ALLG committee. A
cost recovery fee will likely apply for retrieval of clinical data.
I realise that these samples have not been screened for potential pathogens and therefore
may result in severe illness or even death if not handled properly. The responsibility for the
correct handling of the samples lies solely in my hands and is not the responsibility of the
ALLG. Any illness resulting from the mishandling of these samples is not the responsibility
or liability of the ALLG.
I will acknowledge the ALLG in any publications or presentations resulting from work on the
samples provided. ALLG collaborators will be recognised as co-authors on any
publications.
Wording of acknowledgment will be in the form of: “We would like to acknowledge the
Australasian Leukaemia and Lymphoma Group Discovery Centre for the provision of
haematologic malignancy samples for this project. The ALLG Discovery Centre is
supported by The Leukaemia Foundation of Australia funding.”
I agree to provide brief reports to the ALLG on a 12 monthly basis.
Signature of Investigator:
Full name (printed):
7.
________________________Date:___________
___________________________________________
I, the undersigned as Institutional Head, have the authority to execute this agreement on
behalf of the institution detailed below.
Signature of Institution Head:
___________________________________________
Full name (printed):
___________________________________________
Institution Name:
___________________________________________
Institution Address:
___________________________________________
___________________________________________
8
ALLG Discovery Centre
Princess Alexandra Hospital
c/- Haematology/Pathology
Main Building Level 1
Ipswich Road
Woolloongabba
QLD 4102
www.allg.org.au
Improving the treatment and the lives of patients with blood cancers through clinical trial research
8. CHECKLIST
Completed application form
Institutional funds are available
Approval letter(s) for secured funding/grant(s) attached
Ethics Committee approval letter attached
Section 7 Agreement for Sample Use completed and signed
9. HOW TO SUBMIT THE APPLICATION FORM
Email a scanned copy of the application form to:
Megan Ellis
ALLG Discovery Centre Manager
Email: megan_ellis@health.qld.gov.au
Please type in subject line: ‘ALLG Researcher Application for review’
OR
Mail the application form to:
Megan Ellis
ALLG Discovery Centre Manager
c/- Haematology/Pathology
Princess Alexandra Hospital
Main building, Level 1
199 Ipswich Road
Woolloongabba
Queensland AUSTRALIA 4102
9