PI
Approval status and date
TACMASR Requisition #
Application for Use of Biospecimens
from the UACC Biospecimen Repository
Tissue Acquisition and Cellular/Molecular Analysis Shared Resource
University of Arizona Cancer Center, Room 0917, 626-7319 uacc-TACMASS@uacc.arizona.edu
Title of Project
Brief description of project
request
Date submitted
PI Name and Title
PI email and telephone or pager
PI Department
KFS Account Number
Grant Title
Peer reviewed
PI Membership in UACC Program
Contact name and title/position
Email and telephone
Other Contact: name/title/email
PROJECT
Title or Study #
Human Tissue: IRB approval
(please provide pertinent information
in the space below)
Approval from submitting surgeon
NIH
Other (list)
Provide Determination of Human Research if you are
requesting de-identified specimens (no patient identifiers)
Provide IRB approval letter if you are requesting specimens
with identifiable information
Copy of letter/email from contributing surgeon is attached
Not applicable
NOTE: It is the policy of the Biospecimen Oversight
Committee to offer the contributing surgeon the “right of first refusal’
regarding use of the consented specimens he/she submitted to the
UACC Biorepository. *
The responsibility of the TACMASR lab staff is to identify the
surgeon who contributed specimens that will be used for a specific
study, and notify the requesting researcher the name and contact
information of the surgeon, and to request that they contact and/or
collaborate with them.
It is the responsibility of the researcher who is requesting the
specimens to contact the contributing surgeon, obtain a verifiable
response (email or letter), and provide this documentation to
TACMASR as part of the application packet.
*If the surgeon is no longer at this institution and has not left
specific instructions regarding distribution and use of such
specimens, then the Committee accepts responsibility.
TACMASR USE ONLY
Date Received:
Revised: 2/8/2016 | Document1
Document1
Received By:
Completed by:
Date completed:
Version 0.4 | Page 1
PI
Approval status and date
TACMASR Requisition #
Application for Use of Biospecimens
from the UACC Biospecimen Repository
Tissue Acquisition and Cellular/Molecular Analysis Shared Resource
University of Arizona Cancer Center, Room 0917, 626-7319 uacc-TACMASS@uacc.arizona.edu
Please list other collaborators
who may be involved with this
project
Describe the specimens you are
requesting (check all that apply)
Specimen Preparation (check all that apply)
Select tissues that fit my criteria (describe below)
Cut tissue sections
Prepare fluids
Slide read out and/or scoring by pathologist
Slide photography/scanning
Other, describe below
IHC –For ALL requests, fill out “IHC Additional Information”
form.
Once all of your information is received, your project will be placed in
our IHC queue. Please keep in contact with TACMASR for periodic
updates as needed.
Tissue - FFPE
Tissue - Frozen
Tissue - RNALater
Serum
Plasma
Whole blood
Genomic DNA
Urine
Other - describe
Section 2 – Describe Your Project Requirements
Specific Proposal – Briefly state the objectives of this study, preliminary data supporting the hypothesis,
research plan, and expected outcome. You may provide attachments.
Describe your specific request to TACMASR. Include details that will help TACMASR meet your specific
criteria for specimens.
Methods – Briefly describe who will analyze the biological specimens, and assays and methods to be used.
Outline your timeframe – When will you need biological specimens, how long will analysis take, etc.
Organ specific disease state – e.g., tumor and normal tissue from same patient
Specific demographic criteria – Only those that are needed for your analytical purposes (e.g., age, gender)
Criteria for pathologic diagnosis of patient tissues – please be specific
TACMASR USE ONLY
Date Received:
Revised: 2/8/2016 | Document1
Document1
Received By:
Completed by:
Date completed:
Version 0.4 | Page 2
PI
TACMASR Requisition #
Approval status and date
Tissue Quantity: number of sections, section thickness, approximate mg, etc.
Tissue preparation: How do you need the tissue prepared for you?
Criteria for tissue samples: e.g., all cancer, all normal, etc.
Volume and form of sample needed: e.g., 300ul aliquot of serum, frozen, etc.
Number of biological specimens: i.e., Number of different patient samples
Other criteria or specific requests: describe in detail.
I agree not to release or share samples with any other individual or institution without approval from the Biospecimen
Oversight Committee.
I agree to submit results for publication within one year of assay completion.
Authorship on publications will be determined prior to release of samples.
I agree to maintain sample/data confidentiality.
I agree to acknowledge assistance provided by the TACMASR:
Remember to cite the University of Arizona Cancer Center Support Grant, NIH CA023074.”
Remember to send publication information to TACMASR!
Signature of Requesting Investigator (electronic or original)
Submit an electronic version of the Application form, IRB
correspondence, and attachments to:
UACC-TACMASS@uacc.arizona.edu
Room 3963 626-7319
Date:
For questions contact:
Setsuko K. Chambers, MD
PI of UACC Biospecimen Repository
schambers@uacc.arizona.edu
Achyut Bhattacharyya, MD
Co-Director of TACMASR
abhattac@email.arizona.edu
Charmi Patel, MD
Co-Director of TACMASR
charmipatel@email.arizona.edu
For TACMASR use. Do not write below this line.
Section 3 – TACMASR response
Be as specific as possible
TACMASR Response
TACMASR USE ONLY
Date Received:
Revised: 2/8/2016 | Document1
Document1
Received By:
Completed by:
Date completed:
Version 0.4 | Page 3
PI
Approval status and date
TACMASR Requisition #
Are appropriate and sufficient
specimens available?
Can this request be met by
TACMASR?
Will the request exhaust any
specimens that are used?
How will the request be met?
How will the specimens be deidentified to the researcher?
Describe the work that
TACMASR will perform
Has the contributing surgeon
been contacted by TACMASR?
Other criteria or comments
Section 4 – Biorepository Oversight Committee Approval (may be approved by email)
Setsuko Chambers, MD
Comments:
Yes
No Date
Charmi Patel, MD
Comments:
Yes
No Date
Amanda Baker, PhD, PharmD
Comments:
Yes
No Date
Achyut Bhattacharyya, MD
Comments:
Yes
No Date
Ron Heimark, PhD
Comments:
Yes
No Date
James Warneke, MD
Comments:
Yes
No Date
Wenxin Zheng, MD
Comments:
Yes
No Date
Summary:
Yes
Approved by a quorum of Oversight Committee members
No
Date __________
Comments:
TACMASR USE ONLY
Date Received:
Revised: 2/8/2016 | Document1
Document1
Received By:
Completed by:
Date completed:
Version 0.4 | Page 4
PI
Approval status and date
TACMASR Requisition #
.
TACMASR USE ONLY
Date Received:
Revised: 2/8/2016 | Document1
Document1
Received By:
Completed by:
Date completed:
Version 0.4 | Page 5