Department of
Pathology
University Biospecimen Repository
Specimen Request
PROCEDURES
1. Requests for biospecimens must be made on the University Biospecimen Repository
Specimen Request Form (SRF) below. Requests must include a completed and
signed SRF, a protocol and any other relevant study materials.
2. Specimen request documents are to be sent to UBR@umc.edu.
3. All cancer-related requests will be reviewed by the Director of the Cancer Institute
and Cancer Institute Deputy Director for Basic Science.
4. Priority will be given based on following criteria:
a. Investigators with federal grant funding (i.e. NIH, DOD, etc)
b. Availability of specimens (requests cannot exceed 50% of current inventory)
c. For Pilot studies/no grant funding: 1 page written justification is required
5. Requests involving fluids will be reviewed by a utilization review committee.
6. Institutional Biosafety Committee registration approval is required for all research
studies involving unfixed human or other primate tissues or fluids that are not carried
out entirely in Joint Commission regulated clinical space or CAP or CLIA- certified
diagnostic facility. Investigators must provide copy of the IBC approval memo or
CAP or CLIA Certificate for research lab where work will be performed.
7. Although IRB approval is not required at time of biospecimen request, IRB approval
is required for the release of biospecimens to investigator.
UBR - SRF v1
Department of
Pathology
University Biospecimen Repository
Specimen Request
CONDITIONS
1. University Biospecimen Repository (UBR) specimens must be used in the manner
described in the SRF and protocol. Any revisions made to the protocol must be
communicated to the UBR. A revised copy of the protocol along with the IRB
Request for Changes Approval Letter must be submitted to the UBR.
2. UBR specimens will be provided to investigators without any patient identifiers.
Investigators will not access protected health information linked to specimens except
as specifically approved by IRB.
3. UBR specimens must not be given, shared or distributed to any third party or
collaborator not listed on SRF.
4. UBR specimens must not be sold to any third party.
5. Some specimens have been contributed by clinicians on the condition that they be
included in the decision to release specimens. In such cases, this will be made known
to the requesting investigator.
6. Investigator is responsible for appropriate handling of human biological material. No
responsibility will be taken by the UBR for injury or illness that may occur to
investigator and/or staff handling the specimens.
7. Investigators are required to ensure that any shipment of material to third party users
be carried out according to USDOT guidelines.
8. The UBR requests that any publications/abstracts resulting from use of UBR
specimens include the following statement in the acknowledgements: “Tissue
samples were provided by the University of Mississippi Medical Center - University
Biospecimen Repository.” Copies of abstracts and/or publications need to be
submitted to the UBR.
UBR - SRF v1
Department of
Pathology
University Biospecimen Repository
Specimen Request
PRINCIPAL INVESTIGATOR INFORMATION
First Name:
Last Name:
Institution:
UMMC
Academic Institution
Commercial
Address:
Institution:
Department:
Address 1:
Address 2:
City:
State:
Telephone:
Zip code:
Fax:
Email:
PROJECT INFORMATION
Project Title:
IRB Review:
Approved
IRB#:
Pending
IRB Expiration Date:
IRB APPROVAL IS REQUIRED TO OBTAIN BIOSPECIMENS
Institutional Biosafety Committee Registration:
Approved
Pending
Approval Date:
Location/Room #:
Funding Source:
Grant#:
Account # to be charged:
UBR - SRF v1
Grant Start Date:
Activity #:
Grant End Date:
Department of
Pathology
University Biospecimen Repository
Specimen Request
Brief description of project (attach protocol):
Collaborators:
BIOSPECIMEN REQUEST
Anatomic Site:
Subtype (if known):
Diagnosis:
Tumor
Normal
Processing:
Frozen
Fresh
Other:
Paraffin-embedded
Total number of specimens requested:
If requesting FLUID biospecimens (Max. 2ml/case) :
LIMITED QUANTITIES – APPROVAL FROM SUBCOMMITTEE
Serum Volume:
ml
Plasma Volume:
ml
Buffy Coat
Total number of specimens requested:
UBR - SRF v1
Department of
Pathology
University Biospecimen Repository
Specimen Request
Donor Demographics:
Gender:
Race:
Male
Female
Any
Any
Donor History:
Standard Information provided at no additional cost includes age, gender, race.
Requests for additional information, including prior therapy questions, incur an additional fee for chart
review.
Additional Chart Review Required:
Yes
No
Review Information Requested:
By signing below, I agree to the University Biospecimen Repository Procedures and Conditions.
I understand that I am fully responsible for the research performed using the specimens obtained
from the UBR, and the specimens will be used for the research work as described in this SRF, as
approved by the IRB. I have provided truthful information on the nature of my research study.
_____________________________
Principal Investigator Signature
__________________
Date
RETURN BY EMAIL TO: UBR@UMC.EDU
UBR - SRF v1