Application rec’d_____________ HRPO/IRB Approval rec’d_____________ Rev’d and approved______________ Request D______________
Application for Services
Washington University School of Medicine
Translational Cardiovascular Biobank & Repository (TCBR)
**For use by Washington University Investigators**
Return completed form to Kathryn Yamada at Box 8086; or FAX to 314-362-0186.
I. DIRECTIONS: Please fill out this application completely for consideration for the processing and use of
tissue samples by the laboratory personnel who fall under the supervision of the PI listed below.
Please note that the information requested is necessary for the TCBR to process your request, and to ensure that
the TCBR operates within the guidelines of our Institutional Review Board (IRB) protocol and all applicable
federal, state and institutional guidelines. When submitting a written request for services:
A. Please type or print clearly.
B. Please be specific and complete. Any confusion or omission will delay processing.
C. Patient identity is confidential. Disbursed samples will be coded.
D. Shipping costs will be the responsibility of the requestor.
E. YOUR HUMAN SUBJECTS APPROVAL MUST BE ATTACHED TO THIS FORM.
II. INVESTIGATOR:
A.
Principal Investigator Name
(Last, First, MI):
PI’s Degree(s):
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PI’s Title:
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PI’s Date of CITI Training:
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Mailing Address
Institution:
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Department:
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Room/Building/Campus Box/Mail Stop:
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Street Address:
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City, State, Zip Code:
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Telephone:
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FAX:
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E-mail:
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Copyright 2009-2012. Washington University School of Medicine Translational Cardiovascular Biobank & Repository.
Reproduction of this form, making imitative works or spreading information contained within is unauthorized without expressed
written permission from the copyright holder. Copyright holder has “exclusive rights”.
B.
Laboratory Contact:
Telephone:
E-mail:
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Billing Contact:
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Telephone:
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FAX:
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E-mail:
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Funding Source (NIH, AHA, Departmental, if
other, please specify):
Grant ID Number:
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Department
(4 digit) Code:
Courier Account Number
(if receiving shipments):
WUMS (5 digit)
Fund Number:
C.
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III. IRB APPROVAL (if requesting human tissue or data):
A. IRB Protocol Number:
B. IRB Protocol Approval/Expiration Dates:
C. Study title and summary of the proposed research on the tissues, data and/or services that you are
requesting from the TCBR. PLEASE INCLUDE HOW MANY SAMPLES YOU ARE REQUESTING, THE
RATIONALE FOR YOUR REQUEST, AND PRECISELY HOW SAMPLES WILL BE USED (SAMPLE N’S,
STATISTICAL POWER, ETC.).
PLEASE BE SPECIFIC AND INCLUDE AS MUCH DETAIL AS POSSIBLE TO
HELP IN OUR EVALUATION, PRIORITIZATION AND ADJUDICATION OF YOUR REQUEST.
YOU MAY USE
THE BOXES THAT FOLLOW, BUT PLEASE USE ADDITIONAL PAGES IF NECESSARY.
Objectives and significance of project:
Brief description of methods including sample n’s:
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Copyright 2009-2012. Washington University School of Medicine Translational Cardiovascular Biobank & Repository.
Reproduction of this form, making imitative works or spreading information contained within is unauthorized without expressed
written permission from the copyright holder. Copyright holder has “exclusive rights”.
Brief description of analysis plan including statistical analyses:
Lay summary of overall study goals (may be publically posted on the TCBR or CDI website):
IV. SERVICES REQUESTED
Check Service(s) Requested:
A. Non-failing (“control”) human cardiac tissue, frozen
Please specify anatomical site, etc.:
Amount (mg) requested:
x $15 per 50 - 90 mg = $
x $100 per 100-200 mg = $
>200 mg, must discuss with Dr. Yamada for pricing and availability
3
Copyright 2009-2012. Washington University School of Medicine Translational Cardiovascular Biobank & Repository.
Reproduction of this form, making imitative works or spreading information contained within is unauthorized without expressed
written permission from the copyright holder. Copyright holder has “exclusive rights”.
Check Service(s) Requested:
B. Non-failing (“control”) human cardiac tissue, RNAlater-treated
Please specify anatomical site, etc.:
Amount (mg) requested:
x $20 per 50 - 90 mg = $
x $100 per 100-200 mg = $
>200 mg, must discuss with Dr. Yamada for pricing and availability
C. Non-failing (“control”) human cardiac tissue, formalin-fixed
Please specify anatomical site, etc.:
Amount (mg) requested:
x $20 per 50 - 90 mg = $
x $100 per 100-200 mg = $
>200 mg, must discuss with Dr. Yamada for pricing and availability
D. Failing human cardiac tissue, frozen
Please specify anatomical site, etc.:
Amount (mg) requested:
x $20 per 50 - 90 mg = $
x $100 per 100-200 mg = $
>200 mg, must discuss with Dr. Yamada for pricing and availability
E. Failing human cardiac tissue, RNAlater-treated
Please specify anatomical site, etc.:
Amount (mg) requested:
x $25 per 50 - 90 mg = $
x $100 per 100-200 mg = $
>200 mg, must discuss with Dr. Yamada for pricing and availability
F. Failing human cardiac tissue, formalin-fixed
Please specify anatomical site, etc.:
Amount (mg) requested:
x $25 per 50 - 90 mg = $
x $100 per 100-200 mg = $
>200 mg, must discuss with Dr. Yamada for pricing and availability
G. Additional clinical information requested
Please specify:
hr x $50 per hr = $
H. Non-failing human cardiac myocytes, fresh
Please specify:
(Must discuss with Dr. Yamada for pricing and availability)
I. Non-failing human cardiac myocytes, frozen
Please specify:
(Must discuss with Dr. Yamada for pricing and availability)
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Copyright 2009-2012. Washington University School of Medicine Translational Cardiovascular Biobank & Repository.
Reproduction of this form, making imitative works or spreading information contained within is unauthorized without expressed
written permission from the copyright holder. Copyright holder has “exclusive rights”.
Check Service(s) Requested:
J. Normal canine cardiac tissue, frozen
Please specify anatomical site, etc.:
Amount (mg) requested:
x $10 per 50 - 90 mg = $
x $50 per 100-200 mg = $
>200 mg, must discuss with Dr. Yamada for pricing and availability
K. Normal canine cardiac tissue, RNAlater-treated
Please specify anatomical site, etc.:
Amount (mg) requested:
x $15 per 50 - 90 mg = $
x $50 per 100-200 mg = $
>200 mg, must discuss with Dr. Yamada for pricing and availability
L. Normal canine cardiac myocytes, fresh
Please specify:
(Must discuss with Dr. Yamada for pricing and availability)
M. Normal canine cardiac myocytes, frozen
Please specify:
(Must discuss with Dr. Yamada for pricing and availability)
N. Consultation
Please specify:
(Must discuss with Dr. Yamada for pricing)
O. Contracted tissue procurement
Please specify:
(Must discuss with Dr. Yamada for pricing)
P. Blood/blood products
(Must discuss with Dr. Yamada for pricing)
Q. Raw experimental data/access to data
(Must discuss with Dr. Yamada for pricing)
R. Please specify any additional relevant information (if applicable) that you would like the TCBR to
review when the TCBR considers this request:
V. DISCLAIMERS AND TERMS
A. Prior IRB approval must be obtained by the investigator.
B. The recipient investigator agrees that the research material and information to be provided by the TCBR will be
used only for the research purposes specified in this application and in their IRB protocol and as otherwise
required by law, and that material and information received from the TCBR will not be sold or distributed to third
parties, nor used to produce commercial products including the production of cells or cell products for sale.
C. Although the TCBR attempts to avoid supplying tissues contaminated with infectious agents such as HIV, HBV
and HCV, ALL TISSUES SHOULD BE HANDLED AS IF POTENTIALLY INFECTIOUS. The TCBR will not
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Copyright 2009-2012. Washington University School of Medicine Translational Cardiovascular Biobank & Repository.
Reproduction of this form, making imitative works or spreading information contained within is unauthorized without expressed
written permission from the copyright holder. Copyright holder has “exclusive rights”.
D.
E.
F.
G.
be liable for any injury (including death), damage or loss that may arise or may affect or involve the investigator,
any personnel or any other party either directly or indirectly from their use.
The recipient investigator assumes all risks and responsibility in connection with receipt, handling, storage, use,
or disposal of tissues, including informing and training all personnel in the dangers and procedures for safe
handling of these and other human tissues. The investigator agrees to indemnify and hold harmless Washington
University, the TCBR and its staff from any and all claims, costs, damages or expenses resulting from any injury
(including death), damage or loss that may arise from the receipt, handling, storage, use, or disposal of tissues
provided by the TCBR.
The recipient investigator acknowledges that the tissues received are not sterile.
The recipient investigator and research personnel acknowledge that the tissue samples will be coded, and that no
identifiable information will be given or available to the recipients; they further agree not to request or expect any
identifiable patient information to be provided by the TCBR.
The recipient investigator agrees to acknowledge the TCBR, Washington University ICTS and the Children’s
Discovery Institute in any publications or documents that arise from use of this resource as follows:
"We acknowledge the Translational Cardiovascular Biobank & Repository at Washington University
which is supported by NIH/CTSA grant UL1 TR000448, a grant from the Children’s Discovery Institute of
Washington University and St. Louis Children’s Hospital, and funds from the Richard J. Wilkinson
Trust.”
BY MY SIGNATURE I AGREE TO THE TERMS SET FORTH IN THE ABOVE AGREEMENT AND I AGREE TO
PAY THE INVOICES FROM THE TCBR FOR THE MATERIALS AND/OR SERVICES I HAVE REQUESTED.
Print Name of Principal Investigator:
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Signature of Principal Investigator:
Date: Click here to enter text.
Print Name of Recipient:
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Recipient Signature:
Date: Click here to enter text.
TCBR:
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Signature:
Date: Click here to enter text.
FOR TCBR USE ONLY
IRB Approval Attached and Reviewed
Yes________
No________
TCBR Advisory Committee Approved
Yes________
No________
Date_______________
Tissue Disbursed by:_______________ on Date:_________________
Total Charges
$_______________________
TCBR Staff Member Initial
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_____________
Copyright 2009-2012. Washington University School of Medicine Translational Cardiovascular Biobank & Repository.
Reproduction of this form, making imitative works or spreading information contained within is unauthorized without expressed
written permission from the copyright holder. Copyright holder has “exclusive rights”.