KI Biobank
Withdrawal Order
Withdrawal order and donor identity
To withdraw samples from KI Biobank, please fill in this form and prepare an excel file
with donor identity numbers in the form of customer donor key (CDK) or referral identity
(RID). Email the form and the excel file to biobank-lab@ki.se. In addition please send
this form signed by the principal investigator via ordinary mail to:
KI Biobank
Karolinska Institutet
Box 281
171 77 Stockholm
Sample collection details
Sample collection (study)
to withdraw samples from:
Principal investigator of
sample collection:
Is the original ethical
approval applicable?
Yes (Double click in order to edit check box)
No
If no, please state the new ethical approval Dnr:
……………………………………….
Customer details
Karolinska Institutet
Department:
Version:
Gäller från:
0360-5
2013-10-04
Utfärdare:
Godkännare:
Camilla Lagerberg
Tove Rylander-Rudqvist
1 (5)
Other organisation:
Orderer/Contact person:
Phone:
E-mail:
Invoice address (including
ZZ-reference code within
KI):
Delivery details
Will the samples be sent
to a laboratory outside
Karolinska Institutet?
Yes
No
If yes, a Material Transfer Agreement (MTA) is needed. MTA can be down-loaded from:
http://ki.se/kibiobank . Please click at Biobank & Prices and then click at Withdrawal of
Samples.
Please note that the MTA has to be signed by all parties and received by KI Biobank
before sample delivery.
Name and complete
address of receiving
department/organization:
Contact person:
Name:
Phone:
E-mail:
Version:
Gäller från:
0360-5
2013-10-04
Utfärdare:
Godkännare:
Camilla Lagerberg
Tove Rylander-Rudqvist
2 (5)
Sample information
delivery files should be
sent to the following email address(es):
Sample information
Type of samples to
withdraw:
(Please select one sample
type per order, e.g. create
one withdrawal order for
each sample type.)
DNA from Blood
Serum
DNA from Saliva
Urine
Whole blood
Other, please specify:
Saliva
……………………………
Plasma
……………………………
Number of samples to
withdraw:
DNA samples
DNA normalization = dilution of all samples to the same concentration in 96 well format.
Note that all DNA samples in a study must be normalized to the same selected
concentration.
Choose format for the normalized DNA:
Abgene 1.2 ml 2D tubes (required for storage at KI Biobank)

to concentration: ………. ng/µl (20-100 ng/µl)

to volume: ………. µl (200-500 µl)
Abgene 0.8 ml Deep well plate

to concentration: ………. ng/µl (20-100 ng/µl)

to volume: ………. µl (200-500 µl)
Version:
Gäller från:
0360-5
2013-10-04
Utfärdare:
Godkännare:
Camilla Lagerberg
Tove Rylander-Rudqvist
3 (5)
Normalized DNA delivery on Abgene PCR plate
Sample volume:………… µl (5-170 µl)
Please select plate layout:
Empty wells at the end of the plate, No ………. (0 = 96 samples per plate)
Randomly placed empty wells, select: 2 / 4 / 6
Two randomly placed duplicate samples and 4 randomly placed empty wells
Stock DNA delivery on Abgene PCR plate:
Sample volume:………… µl (5-170 µl)
Please select plate layout:
Empty wells at the end of the plate, No ………. (0 = 96 samples per plate)
Randomly placed empty wells, select: 2 / 4 / 6
Additional request:
Other sample types
Tubes
Additional request:
Version:
Gäller från:
0360-5
2013-10-04
Utfärdare:
Godkännare:
Camilla Lagerberg
Tove Rylander-Rudqvist
4 (5)
This agreement is a mutual understanding between the principal investigator of the sample
collection and the orderer/contact person to use requested samples as specified in the
ethical approval.
Signature
Date:
Signature of principal
investigator:
Clarification of signature:
Version:
Gäller från:
0360-5
2013-10-04
Utfärdare:
Godkännare:
Camilla Lagerberg
Tove Rylander-Rudqvist
5 (5)