KI Biobank Withdrawal Order (REMP-tubes) 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 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: 0867-3 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 contact Cecilia Björkdahl, contract administrator, at cecilia.bjorkdahl@ki.se for questions and help regarding the MTA. 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: Version: Gäller från: 0867-3 2013-10-04 Utfärdare: Godkännare: Camilla Lagerberg Tove Rylander-Rudqvist 2 (5) E-mail: Sample information delivery files should be delivered to the following e-mail address(es): Sample information Type of samples to withdraw: DNA from Blood Serum DNA from Saliva Urine (Please select one sample Whole blood Other, please specify: type per order, e.g. create one withdrawal order for each sample type.) …………………………. Saliva Plasma Sample delivery format REMP- tubes Empty wells at the end of the REMP- container: No ………. (0 = 96 samples per plate) Additional request: Abgene PCR plate Sample volume: ……… µl (5-160 µl) Empty wells at the end of the PCR plate: No ………. (0 = 96 samples per plate) Version: Gäller från: 0867-3 2013-10-04 Utfärdare: Godkännare: Camilla Lagerberg Tove Rylander-Rudqvist 3 (5) Additional request: Other sample delivery format: Number of samples Number of samples = referral identity (RID) numbers: Number of aliquots per referral identity (RID) number: This agreement is a mutual understanding between the principal investigator of the sample collection and the project leader to use requested samples as specified in the ethical approval. Signature Date: Signature of principal investigator: Clarification of signature: Version: Gäller från: 0867-3 2013-10-04 Utfärdare: Godkännare: Camilla Lagerberg Tove Rylander-Rudqvist 4 (5) Version: Gäller från: 0867-3 2013-10-04 Utfärdare: Godkännare: Camilla Lagerberg Tove Rylander-Rudqvist 5 (5)