DATES
Application Rec’d
Human Subjects Rec’d
Reviewed & Approved
Added to Req. List
Guidelines Sent
REQUEST FOR SERVICES
UAB COMPREHENSIVE CANCER CENTER
TISSUE PROCUREMENT FACILITY
I.
DIRECTIONS
The information requested in these forms is necessary to ensure that your request for tissue and other
services is correctly documented.
When submitting a written request for services:
A.
Please neatly print or type.
B.
Please be specific about the handling of tissue specimens (i.e., need for sterility, transport media,
refrigeration status, etc.).
C.
All samples will be coded and prepared as specimens at a processing fee of $20/specimen.
Patient identification is confidential.
D.
Send your completed forms to:
Katherine C. Sexton
Tissue Procurement Facility
ZRB 449 (Zip 0007)
For additional information contact us by phone (934-6071), fax (934-0816) or e-mail
(sexton@uab.edu).
II.
INVESTIGATOR DATA
A.
Principal Investigator: ____________________________________________________
Investigator’s Title: ______________________________________________________
Department: ___________________________________________________________
Campus Address: _______________________________________________________
Phone (Day): _____________________ (Nights/Weekends): _____________________
Contact Person: _________________________ Phone: _________________________
FAX Number at which you may be notified: ___________________________________
E-Mail Address: _________________________________________________________
III.
SERVICES REQUESTED
A.
Human Tissue Specimen Criteria:
1.
Anatomic Site or Tissue Type: ________________________________________
_____Benign; _____Malignant; _____Normal; _____Diseased; ______Other
2.
Tissue Source: ____Surgical ____Autopsy. If autopsy material is acceptable, specify
time constraint: within ____hrs. after death
3.
Will you accept tissue from patients previously treated with:
Radiation? __________ Chemotherapy? __________
4.
Patient Limitations (i.e., age, race, sex, or other limiting characteristics):
________________________________________________________________
________________________________________________________________
B.
5.
Is normal matched tissue required from the same patient?
______Yes; ______No; ______If available
6.
Amount of tissue required (minimum to maximum size or dimension):
________________________________________________________________
7.
Must specimen be sterile? ______Yes; ______No; ______As clean as possible.
8.
Frequency tissue is needed: _________________________________________
9.
Total number of specimens needed: ___________________________________
10.
Requested starting date to receive tissue: _______________________________
(NOTE: Please notify Tissue Procurement ASAP if your needs change).
Preparation and Preservation of Specimens (please mark only those that apply):
______ Fresh. Indicate media requirements (Saline, RPMI, wrap in wet gauze, keep dry, etc.):
_____________________________________________________________________________
______ Frozen. Indicate freezing requirements (fresh-frozen, OCT, etc.):
_____________________________________________________________________________
______ Fixed. Indicate fixative requirements (10% BNF, etc.): ___________________________
_____________________________________________________________________________
C.
Specimen Information Required
Anatomic site of tissue, provisional diagnosis, final diagnosis, and patient age, sex and
race (if available will be provided for all specimens. Other information needed (explain):
______________________________________________________________________
______________________________________________________________________
APPLICATION FORM
UAB COMPREHENSIVE CANCER CENTER
TISSUE PROCUREMENT FACILITY
I.
Agreement for use of Tissues Provided from the Tissue Procurement Facility
I hereby agree that the tissues provided by the Tissue Procurement Facility will be used for
research purposes only. Tissues shall not be sold or distributed further to third parties. The tissues are
provided as a service to the research community without warranty or merchantability of fitness for a
particular purpose or any other warranty, express or implied.
II.
Tissues of Human Origin Agreement
I understand that although the Tissue Procurement Facility attempts to avoid supplying tissues
contaminated with highly infectious agents such as hepatitis, HTLV-III, etc., all tissues should be handled
as if potentially infectious. The Tissue Procurement Facility accepts no responsibility for any injury
(including death), damage or loss that may arise either directly or indirectly from the use of these tissues.
I assume all risks and responsibility in connection with the receipt, handling, storage and use of tissues. I,
as the investigator receiving these tissues, also ASSUME
FULL
RESPONSIBILITY
FOR
INFORMING AND TRAINING ALL PERSONNEL IN THE DANGERS AND PROCEDURES FOR
SAFE HANDLING OF THESE AND ALL OTHER HUMAN TISSUES. I further agree to indemnify
and hold harmless the Tissue Procurement Facility from any claims, costs, damages or expenses resulting
from any injury (including death), damage or loss that may arise from the use of the tissues provided by
the Tissue Procurement Facility.
III.
Acknowledgement Agreement
I hereby agree to acknowledge the contribution of the Tissue Procurement Facility in all
publications resulting from the use of these tissues.
BY MY SIGNATURE I AGREE TO THE TERMS SET FORTH IN AGREEMENTS I-III
ABOVE:
________________________________ ______________________________________
Typed or Printed Name
Title
________________________________ ______________________________________
Signature
Date
Division or Department
IV.
Are you a member of the UAB Comprehensive Cancer Center or will any tissues you receive from this
facility support projects funded through the Cancer Center?
______ Yes
______ No
If you answered “yes”, please list below all grants which utilize tissues supplied by our Facility (This
information will be useful for the preparation of our grant renewal for the continuation of this facility):
Grant # or
Identification
V.
Funding Source
(Agency)
Period of
Support
Please provide us with a short research summary of your proposed research intent with the tissues you are
requesting.
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
VI.
Investigators who wish to receive human tissues through the Tissue Procurement Facility MUST HAVE
human use approval or exemption. A COPY OF THAT APPROVED EXEMPTION SHOULD BE
RETURNED WITH THIS FORM. If you do not have this approval, it can be obtained through the
Institutional Review Board (Human Use) Committee. Kathy Sexton, Assistant Director of the Tissue
Procurement Facility, can provide you with the necessary forms. She can be contacted at extension 46071, or ZRB 449.