FUNCTIONAL PROTEOMICS SAMPLE SUMBISSION FORM- ACADEMIC
REVERSE PHASE PROTEIN ARRAY
INSTRUCTIONS: The following information is required prior to sample submission. Please complete and email the
form to CCSGRPPA@mdanderson.org. Once we have reviewed the Submission Forms you will be notified via email
with further instruction for sample submission. DO NOT submit samples prior to notification that your submission
form has been approved.
REQUESTOR INFORMATION
Name
Department
Address
Phone
Email address
Primary
Contact:
Principal
Investigator
& Employee
ID:
Bill to:
SAMPLE INFORMATION
Please note that we will not accept any samples linked to patient sensitive information.
Number of samples being submitted:
(We request samples to be arranged in 1.5mlmicrocentrifuge tubes not in 96-well plates.)
Volume of samples (minimum of 40ul per sample
required)
Do you want us to perform technical duplicate? Note:
This will require a minimum of 80ul per sample and will
double the cost charge.
Did you set up your samples in the same volume?
Lysis Buffer Used:
Sample Origin- check all that apply:
****If submitting tissue or cell line other than mouse or
human please consult with the RPPA team prior to
submission of this form by contacting
CCSGRPPA@mdanderson.org*****
PROTEIN CONCENTRATION


YES
NO












YES
_______ ul/sample
NO (If No, specify volume on sample list form.)
Buffer Provided by Proteomics Core
Prepared according to Core Recipes
Other—Provide Gradients here:____________
Human Cell Lines
Mouse Cell Lines
Other Cell Lines- consult RPPA team
Human Tumor Tissue
Mouse Tissue
Tissue from Other Origin- consult RPPA team
Other- consult RPPA team
Have you determined the protein concentration in
your samples?
Have you adjusted the protein concentration in your
samples?
Have you added SDS and -ME to your samples? (At
least 1% SDS at final concentration is required for
protein denature. Please add additional SDS and -ME
even with RIPA buffer.)
How many data sets would you like? Please specify in
your sample list which sample will go in what data set.
(Each additional set will be an extra $100 charge.)
What is to happen with residual material after analysis?






YES
NO
YES
 Non-denatured (1.5g/l; no less than
0.75g/l)_______

SDS denatured (1.0g/l; No less than
0.5g/l)__________
NO
YES
NO
 DESTROY
 RETURN TO SUBMITTER (NOTE: RETURN OF
RESIDUAL MATERIALS IS SUBJECT TO SERVICE
CHARGE OF $250.00 PLUS SHIPPING COST)
RPPA SERVICE CHARGE
Per Sample for 130 antibodies
PRICE
$100 processing fee for each data set
Customers from the Texas Medical Center
Customers from Academic Institutions outside the Texas
Medical Center
Is Sample preparation necessary from tumor tissue? If yes:
(Samples from the Texas Medical Center will not be charged
overhead)
Additional antibody (from MDACC list)
Additional antibody (Investigator supplied list)
Return of residual materials **
TOTAL



# of SAMPLES
Overhead
TOTAL
$100.00
$40.00
$65.00
None
19%
$16.00
19%
$300.00
$750.00
$250.00
Additional antibody (from MDACC alternate antibody list) – $300 per sample set for each antibody
Investigator supplied antibody - $750 per sample set for each antibody
Processing fee - $100 per data set for a heatmap of unsupervised hierarchical cluster and a heatmap of “sample in the order as you
submitted”
Internal MDACC IDT information
CO/CENTER: (8 digits):
AUTHORIZED SIGNATURE/DATE:
** FEDEX ACCOUNT NUMBER if requesting return of materials:
I certify that I am authorized to sign on this account and, to the best of my knowledge, funds are available.
Internal MDACC Storage information (For Internal Purpose Only)
Sample Submission Date
(For Internal Purpose only)
Once you have received an approval of your submission form from CCSGRPPA@mdanderson.org please include the original
signed hard copy with your sample shipment. For further questions please call: 713-792-5743.