The University of Hong Kong
Department of Surgery
Divisions of Hepatobiliary and Pancreatic Surgery and Liver Transplantation
Tissue Bank
Material Request Form
[Project Summary]
Circulated on:
Approved by:
Prof. K Man
Dr. Tan to Cheung
Dr. Nikki PY Lee
Project title:
Name(s) of investigator(s):
Summary of Project (max. half page):
List the materials in brief (e.g. protein extract of tumor and non-tumor from 20 HCC patients)
[details on next page]
Updated: 10 Dec, 2015
page 1
Tissue Bank
Material Request Form
[Details of requested materials]
1. Specimen details
Requested
Tumor:
No. of samples
Amount of extract
DNA / RNA / protein
n=
__________
each
__________ ug
Non-Tumor
No. of samples
Amount of extract
n=
each
Blood
No. of samples
Amount
n=
each
n=
DNA / RNA / protein
__________
__________ ug
RNA / protein
__________
__________ ug
RNA / protein
__________
__________ ug
DNA / cell/ plasma / serum
__________
__________ ug
__________ ul
DNA / cell/ plasma / serum
__________
__________ ug (DNA)
__________ ul (plasma / serum)
Tissue sections
Paraffin / snap frozen tissue
Tumor / non-tumor / margin
n = __________
No. of sections requested
n = __________
Biopsy Tissues
No. of samples
Approved
Paraffin / snap frozen tissue
__________
__________
__________
__________
2. Samples series
Special request
[attach item 2a]
No special request
[will be assigned a number according to the availability]
2a. Attach a patient list for special request: [attachment page]
Name of clinical trial:
Or, name of an earlier project if association with the earlier data set is needed:
Or, request for a specific patient group:
2b. Provide information of any potential study that a sample set is used parallel to the requested
sample set.
[Project name, sample size, nature of specimens, amount needed, etc]
[no guarantee]
Updated: 10 Dec, 2015
page 2
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 3
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
page 4