The University of Hong Kong
Department of Surgery
Divisions of Hepatobiliary and Pancreatic Surgery and Liver Transplantation
Tissue Bank
Material Request Form
(Additional request of materials)
Circulated on:
Approved by:
Prof. K Man
Dr. Tan to Cheung
Dr. Nikki PY Lee
Project title:
Name(s) of investigator(s):
Reason(s) for additional request:
[Details of additional requested materials]
1. Specimen details
Previously Taken
Now Request
Approved
Tumor:
No. of samples
Amount of extract
n=
each
DNA / RNA / protein DNA / RNA / protein DNA / RNA / protein
__________
__________
__________
__________ ug
__________ ug
__________ ug
Non-Tumor
No. of samples
Amount of extract
n=
each
DNA / RNA / protein DNA / RNA / protein DNA / RNA / protein
__________
__________
__________
__________ ug
__________ ug
__________ ug
Blood
No. of samples
Amount
DNA / plasma / serum DNA / plasma / serum DNA / plasma / serum
n=
each
__________
__________ ug / ul
Tissue sections
Paraffin / frozen tissue
Tumor / non-tumor / margin
n = __________
No. of sections requested
n = __________
Frozen Tissues
Tumor / non-tumor / margin
Weight of frozen tissues
Updated: 10 Dec, 2015
__________
__________ ug / ul
Paraffin / frozen tissue
__________
__________
frozen tissue
frozen tissue
n = __________
_______mg
__________
________mg
page 1
__________
__________ ug / ul
Paraffin / frozen tissue
__________
__________
frozen tissue
__________
_______ mg
2. Samples series
Special request
[Please attach a patient list]
No special request
[will be assigned a number according to the
availability]
Name(s) and signature(s) of investigator(s):
_____________________
Name
_____________________
Signature
_____________________
Date
_____________________
Name
_____________________
Signature
_____________________
Date
_____________________
Name
____________________
Signature
_____________________
Date
Signatures of Tissue Bank Committee Members:
________________________________________
Prof. Kwan Man
_____________________
Date
_______________________________________
Dr. Tan to Cheung
_____________________
Date
________________________________________
Dr. Nikki Pui Yue Lee
_____________________
Date
Signatures for specimen delivery:
Date of receipt of application:
________________
Expected date for collection:
________________
___________________________
Name of Tissue Bank Technician
_____________________
Signature
_____________________
Date
___________________________
Name of Investigator /
Representative of Investigator
_____________________
Signature
_____________________
Date
Updated: 10 Dec, 2015
page 2
HBP Tissue Bank
Department of Surgery HKU
Guidelines For The Amount of Sample Request
Sample type
Assay Type
Amount
provide
200ul
Working
concentration
/
Extraction
method
/
Serum/plasma
ELISA
Protein from
Tissue
RNA from
Tissue
DNA from
Tissue
DNA from
Blood pellet
Paraffin tissue
sections
Western
Blotting
RT-PCR/qPCR
250ug
2ug/ul
5ug
100ng/ul
Urea Buffer
pH8.0
TRIZOL
PCR
2.5ug
50ng/ul
PCR
2.5ug
/
IHC
5 sections
5um
Qiagen DNA
extraction kit
Qiagen DNA
extraction kit
/
Policy for Principle Investigators (PIs) outside department of Surgery
1. Department of Surgery has the right to reserve the clinical samples for PIs within the
department. Only 20% of the volume/amount of each sample can be requested by PIs from
other departments or institutions. For example, if 1 ml of serum is available in our stock, only
200 l of serum can be requested by PIs from other departments under first-come-first-serve
policy.
2. Type(s) of experiment should be clearly described in the request form in order to justify the
reasonable volume/amount. Repeated request of the same sample set is not allowed unless
obtaining special approval from the Tissue Bank Committee.
3. The clinical samples should only be used for the approved studies. Alteration of the original
experiments should be approved by the Tissue Bank Committee.
4. The Surgical Tissue Bank has the right to charge the PIs with the fees for preparation and
delivery of samples.
5. The Tissue Bank Committee has the right to know the research results of the clinical samples.
Any published works based on the clinical samples should be informed to the Tissue Bank
Committee. To encourage our work, it is highly appreciated for PIs to acknowledge “the
Surgical Tissue Bank, Department of Surgery, the University of Hong Kong” in the
publications.
Updated: 10 Dec, 2015
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