635 Barnhill Dr.
VanNuys Med Sci Bldg, Rm: B037
Phone: 317-274-5583; Fax: 317-274-5565; E-mail: transgen@iupui.edu
Please click and/or type in yellow areas. Then, print, sign and send the completed form to above address. Partially filled form is OK, but we need your signature before we can start preparing your samples.
Date requested: Acct # (required):
IRB #: Study # & Name:
Name of Principal Investigator: IUCC member: Yes No
Department/Affiliation:
Contact person and phone number: E-mail:
Sample source (*Human/**Animal – mouse, rat, other/Cell culture):
Sample type (FFPE / Frozen tissue / Blood / Other body fluids):
Services requested (Please check appropriate box)
SAMPLE PREPARATION:
Sample selection
†
:
Nucleic acid extraction:
FFPE DNA extraction
No. of samples
Intact DNA extraction
No. of samples
FFPE RNA extraction
Nucleic acid integrity, quality & quantification:
DNA/RNA quantification with fluorescence
DNA/RNA quality (A260/A280)
RNA integrity with denaturing agarose
Intact RNA extraction
DNA/RNA quantification with A260
DNase treatment
RNA integrity with BioAnalyzer
TYPE OF ASSAY:
Gene expression analysis (DASL, Human Cancer Panel):
Gene expression analysis (DASL, CUSTOM PANEL
†
):
Gene expression analysis (Whole genome, 24000 probes):
Gene expression analysis (Whole genome, 48000 probes):
Genotyping (GoldenGate CUSTOM PANEL † ):
Genotyping (GoldenGate, Whole genome
†
):
Genotyping (GoldenGate Focused content e.g. cancer panel):
Genotyping (GoldenGate Human/Mouse linkage):
DNA Methylation profiling (GoldenGate Methylation Cancer Panel):
DNA Methylation profiling (GoldenGate CUSTOM PANEL
†
):
*By signing this requisition, the Principal Investigator confirms that the collection of these specimens from research subjects, and the sharing of these specimens with Pathology adheres to all regulatory requirements including that of the Institutional Review board (IRB) and HIPPA.
**Studies involving animal tissues must be IACUC-approved
†ANY CUSTOM PANEL, SAMPLE SELECTION and GG Whole Genome requests must be discussed with the core before placing an order.
Investigator: ________________________________________________________________________
Signature: Date:
For Lab Use Only
Reference #: ________________________________ Date Completed: ________________________________

Sample ID List:
1)
2)
19)
20)
21)
22)
23)
24)
25)
26)
27)
28)
29)
30)
31)
32)
33)
34)
3)
4)
5)
6)
7)
8)
9)
10)
11)
12)
13)
14)
15)
16)
17)
18)
35)
36)
37)
38)
39)
40)
41)
42)
43)
44)
45)
46)
47)
48)
49)
50)
67)
68)
69)
70)
71)
72)
73)
74)
75)
76)
77)
78)
79)
80)
81)
82)
51)
52)
53)
54)
55)
56)
57)
58)
59)
60)
61)
62)
63)
64)
65)
66)
83)
84)
85)
86)
87)
88)
89)
90)
91)
92)
93)
94)
95)
96)