Cell Processing Core
Please email a scanned copy of the completed form
with a signature in the Applicant Agreement and IRB
sections, if applicable, to CPC@cchmc.org
Request for Normal Donor Repository Products – CCHMC ONLY
Submit Requests to Cell Processing Core CPC@cchmc.org or Direct Questions to Kevin Link (513-803-1062)
Kevin.Link@cchmc.org; Fax 513-636-1446
INVESTIGATOR INFORMATION
Requestor:
Phone:
Principle Investigator:
Fax:
Mail Location:
Email:
Request Date:
Date needed:
IRB INFORMATION- COMPLETE EITHER 1 OR 2
Documentation of an IRB approved protocol must be provided if the requested product is to be used, in any way, for research that
involves any type of intervention or interaction with a living individual.
1. Protocol Title:
CCHMC IRB #:
Approved from:
to
2. IRB Exempt: With the signature below I confirm that the requested product is not to be used, in any way, for research that
involves any type of intervention or interaction with a living individual and that the use of the requested product is not related to
human research and therefore, an IRB approved protocol is not necessary.
Signature of Applicant:
Date:
PRODUCT REQUEST INFORMATION
Fresh
Cryopreserved
Note: BM, UCB and normal blood products are not tested for blood borne pathogens. Observe Universal Precautions in
handling cells and experimental animals, especially immune deficient mice that sustain growth of human T cells.
Please indicate the amount needed, e.g.: 1e6 cells. Refer to product pricing page for available aliquot sizes. Additional aliquot sizes
may be available upon request. Please specify in comments section “same donor” or “different donors” if multiple units of the same
sample type are requested.
PB
BM
UCB
Mobilized PB
Non-Mob. PB
Unprocessed:
MNC:
CD34 Positive:
CD34 Negative:
Plasma:
Serum:
For PB requests
please indicate the
preferred
anticoagulant.
We also offer skin biopsies and buccal swabs. If you wish to purchase these products, please
indicate your needs in the “other” line.
EDTA
ACD
Sodium Heparin
No Anticoagulant
Other:
Comments:
Manuscript acknowledgement:
Cord Blood: “We thank the Mt. Auburn Ob-Gyn associates and delivery nursing staff at Christ Hospital, Cincinnati for collecting cord blood
samples from normal deliveries.”
All Samples: “We thank the Cell Processing and Manipulation Core in the Translational Cores, and Physicians and Nurses at CCHMC for
obtaining and processing these samples. We also thank the CCHMC Translational Research Trials Office for providing the regulatory and
administrative support for this endeavor.”
**Receive $50.00 Credit for acknowledgement of the Cell Processing Core Laboratory in your published paper. To receive this
discount on your future order please attach a copy and send it in with your next order**
BILLING INFORMATION
Mandatory for All Methods of Payment
GL BU
Fund
Account
Dept.
Mandatory for All Grants, Contracts & Agreements
Project BU
Project ID
Activity ID
Budget Reference
APPLICANT AGREEMENT
The applicant agrees that the samples provided will be used only for the research purposes specified in this application and shall not be sold or distributed free of charge
to third parties. This research specimen may only be utilized in accordance with the protocol referenced in this application as approved by the CCHMC IRB. Any additional
use of this material requires prior review and approval by the CCHMC IRB. The investigator further agrees to acknowledge providers in any publications arising
from use of these products as noted above.
Signature of applicant:
RELEASE DOCUMENTATION (CPC Staff Only)
Date:
Released To:
Initials
Date:
Released By:
Initials
Date:
Notes: