Withdrawal Order (REMP-tubes)

advertisement
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 [email protected] 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 [email protected] 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)
Download