Document L1b. Appendix to “Application for access to sample collection and personal data for
research”
Liquid-based samples, version 4.5
Contact address: info@biobanksverige.se
Page 1
To be completed by the biobank (If applicable)
Date arrived:
Documentation-id:
Sample collection-id:
Appendix 1b: Information about existing liquid-based samples in biobank
Microbiology
Genetics
Chemistry
Immunology
Pharmacology Other:
FOR THE APPLICANT TO FILL IN
1. Study project
Study name (same as specified in 1. Access to sample
collection and personal data for research):
Registration no. of the ethical
review board’s decision.
Study-ID (if applicable)
2. Information concerning the applicant/ Research principal
The chief responsible researcher (researcher primarily responsible
for conducting the study):
Other contact person (if applicable)
Name:
Name:
Work address:
Work address:
Phone:
Phone:
E-mail:
Invoice address (including cost center/ref. invoice if applicable):
E-mail:
Delivery address (to where the samples shall be sent)
Other information (for example delivery date, other participants in project if applicable)
3. Material
A. Number of patients:
Have attached a list with laboratory identification no/national registration no, date of
sample collection and date analysed, appendix:
The list shall be numerically sorted in ascending order for each year
Other wishes:
B. Describe below the type of material requested (type of sample, quantity and preparation):
Describe content and extent. Type of sample tissue, cells/cell
line, blood, serum, plasma, CSF, prepared DNA, urine etc
Number of
patients
Number of
samples
TO BE COMPLETED BY THE BIOBANK
Application for existing samples:
Approved. Terms for approval, see below
Rejected, explanation:
Terms for access to the samples
Additional notes:
Authorized representative of the healthcare principal´s biobank
City:
Date:
Signature:____________________________
Name in capitals:
Local administrator (if applicable):
Desired
volume
Minimum
volume for
analysis