MRC London Neurodegenerative Diseases Brain Bank
REQUEST FOR TISSUE
ACKNOWLEDGEMENT AGREEMENT
1. I undertake to acknowledge the London Neurodegenerative Diseases Brain Bank, Brains for
Dementia Research & the Medical Research Council as the source of tissue in any publication
in any media that arises from my work, and to submit a report on the results of using the tissue,
IRRESPECTIVE OF THE OUTCOME within one year of its issue to the brain bank.
2. The success of a brain tissue bank is gauged by the number and nature of publications
arising from work on the tissue. This is essential for securing future funding for human brain
tissue banks. I understand that the Brain Bank & BDR will submit an annual report to their
funders of tissue supplied and acknowledgements made. I understand that a failure to comply
may impact on decisions to meet future requests for tissue from my institution.
Signature:Click here to enter text.
Print name: Click here to enter text.
Head of Dept Signature:Click here to enter text.
Print name: Click here to enter text.
Requested by:
(List PI’s & Co-PI’s))
Full Address:
(Full name & title)Click here to enter text.
Tel No:
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Email:
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Project Title:
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Please provide a Lay
Summary of the project
(100 to 200 words):
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Fax No:
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Please provide one page scientific summary to include justification, aims & objectives, methods &
details of tissue required. Include sufficient information to enable the brain bank committee to check
the methodology is appropriate to meet the objectives.
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Have you applied to, or received tissue from any other brain banks? Please give details.
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YOUR REQUEST
this a PILOT study (up to around 10 samples)?
No of Cases
Control
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Y
N
Disease 1 (specify)
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Brain Areas (specify)
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No of Cases
Disease 2 (specify)
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Disease 3 (specify)
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Brain Areas (specify)
HOW DO YOU REQUIRE THE TISSUE?
FROZEN TISSUE – SAMPLES (give
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size/weight)
OR NUMBER OF SLIDES
(specify section thickness)
FIXED TISSUE SAMPLE / PARAFFIN
PROCESSED BLOCK? (delete as
applicable & give approx size – note: it is
rare to give out blocks)
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PARAFFIN SECTIONS (specify no. of
slides per brain area & thickness)
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OTHER (eg homogenates, please
specify)
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PROJECT PURPOSE, ETHICAL APPROVAL, FUNDING AND DATA ANALYSIS
Scientific investigation?
Commercial product
development?
Please give your Research Ethics
approval No
Has a research ethics committee
Y
N
Educational project?
Y
N
Y
N
Other (specify)?
Y
N
Y
N
Y
N
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enter text.
Y
N
Please attach a copy of your letter
granting ethical approval
If Yes, are you amending for
previously rejected this study?
resubmission?
If this study is successful do you intend to make an application for ethical approval?
Y
N
Please give details of funding support: Click here to enter text.
Where will the research take place?
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Has the study been peer reviewed
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(give details):
Has the study been statistically reviewed?
How was the number of
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samples decided on?
Where, and by whom will
the analysis of samples and
data be undertaken?
Y
N
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Will any part of the work be Click here to enter text.
delegated to collaborators
(specify)?
Do you foresee any ethical problems, Click here to enter text.
in particular, genetic problems for
families of donors (give details)?
Please send completed form to:
Claire.troakes@kcl.ac.uk
Or to: London Neurodegenerative Diseases Brain Bank
Box PO 65
Institute of Psychiatry
King’s College London
De Crespigny Park
LONDON SE5 8AF
Tel: 020 7848 0290
Fax: 020 7848 0275
FOR BRAIN BANK USE
Application Date:Click here to enter text.
Ethical approval application been submitted?
Applying under Brain Bank/BDR ethical approval?
Date request reviewed by
BDR: Click here to enter text.
If not approved, give reasons /
outcome:
Date request reviewed by Brain
Bank: Click here to enter text.
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Y
Any issues raised
Y
with request?
Tissue use approved by
Brain Bank
BDR
Date of approval:Click here to enter text.
Release tissue when MTA issued?
Date tissue released:Click here to enter text.
Tissue Request Form MAR2013
Y
N
N
N