Pathology Laboratory Tissue Procurement Review Form
Review #
submit to OHSU Anatomic Pathology Division, L471 (503-494-9496)
______
Instructions:
Details of specimen procurement should be specified in the protocol (e.g. 1gr of breast cancer tissue and 1gr of non cancerous breast tissue,
rapidly frozen in 0.1gr aliquots in vials in liquid Nitrogen within 20 minutes of removal from the patient) in order to assess feasibility and
compatibility of diagnostic and research use of tissue. If tissue is to be directly removed by investigators before examination of the specimen
by the Pathology Department, detailed justification should be provided, including assessment of the risk to the patient that diagnostic
information may be lost (This risk should be addressed in the informed consent document). As a general rule, tissue should not be removed
from specimens without direct supervision by Anatomic Pathology Laboratory personnel. This permits appropriate documentation of tissue
removed for research and ensures that only tissues not needed for diagnostic purposes are used for research. In some situations, it may be
possible for the Anatomic Pathology Laboratory to process and maintain custody of research specimens until diagnostic procedures are
completed (in case the materials set aside for research are needed for diagnostic purposes). When diagnosis is completed these materials set
aside for research can be made available to the investigator. Every effort will be made by the Anatomic Pathology Laboratories to
accommodate special requirements for tissue procurement. Fees may be assessed by the laboratory to meet the requirements of protocols
involving effort or materials beyond those used for standard diagnostic purposes
Research Protocol Title:
Principal Investigator:
Department/Mailcode:
Contact person / extension:
Email:
Brief Abstract describing tissue procurement (Attach copy of research protocol and drafts of
relevant consent forms):
Do you plan on obtaining tissue before examination by the Pathology Laboratory?
Yes
No
If yes, provide detailed justification if not included in attached research protocol:
Do you plan on obtaining tissue only from the Oregon Cancer Institute Tissue Bank?
Yes
No
Types of specimens:
05/06/2003
Pathology Laboratory Tissue Procurement Review Form, p. 2
Review #
______
.
Concerns:
Review recommendation:
Approve
Disapprove
Approve with revision (specify):
Reviewed by:
Signature
Surgical Pathology
Cytopatholgoy
Hematopathology
Neuropathology
Date
Dermatopathology
Opthalmalogic Pathology
Oral Pathology
Approved:
Laboratory Director
Anatomic Pathology Laboratories
Dermatopathology Laboratory
Opthalmologic Patholgy Laboratory
Oral Pathology Laboratory
05/06/2003
Date