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Biosample Repository Specimen Request Form

This request form is intended for FCCC/TUHS staff and other Academic/NCI-designated Institutions

If you are not affiliated with an Academic or NCI-designated Institution, please contact Adam Van Dyke, PhD, AVP Innovation & Translational Development

For External Data Requests, please complete an External BRF Data Request

For requests to utilize the Vectra / inForm platforms, please visit our Facility Scheduler

Date of Request

Y-M-D

Is this a prospective request for fresh specimens and/or related data?

* must provide value

Yes, fresh specimen request

No, banked specimen request

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Investigator name

* must provide value

Investigator name

* must provide value

Provide your e-mail

* must provide value

Add additional email for BRF communication (if available)

Is this request for treatment-naïve specimens?

* must provide value

Yes No

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Sample Selection Criteria:
For prospective fresh specimen requests, provide date of surgery (or encounter) and Participant ID / MRN (if available)

For specimen or data requests, provide the list of Specimen IDs (if available)

* must provide value

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Will NGS genomic testing be performed on specimens?

* must provide value

Yes

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Is there a Temple/FCCC Clinician that is involved with or collaborating on this project?

Yes

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Provide name of Clinician(s)

Is it a new request or follow up?

* must provide value

New request

Follow up request

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Please upload a pdf of your approved protocol.

* must provide value

Upload file

Requested specimens listed for approved use in IRB protocol?

* must provide value

Yes No

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Approved IRB# or Letter of Determination

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Approved IRB# or Letter of Determination

* must provide value

Date of Letter of Determination (if applicable)

M-D-Y

Attach Letter of Determination from your IRB (Not Human Research Determination)

Upload file

Date of IRB Expiration

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Date of IRB Expiration

* must provide value

Y-M-D

Number of Days between Request Date and IRB expiration date

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"Date of IRB Expiration" cannot be before the request date.

Please describe relevance of the protocol to the specimens being requested

* must provide value

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Cost Center

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Cost Center

Funded Project

Yes No

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Statistician name

Collaborators

Internal External

Phone

Contact Person

Attachment 1: Upload supporting document or initiation worksheet, if available

Upload file

Attachment 2: Upload supporting document or initiation worksheet, if available

Upload file

Project description: Include hypothesis/purpose. Statistical justification is encouraged for all studies and required for studies requesting >20 samples (excluding TMAs). Guidelines for statistics are provided below:

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Guidelines for satisfying statistical review of Biosample Repository-related protocols

The following statistical considerations will be evaluated for Research Review prior to IRB:

• Testable specific aims
• Precise definitions of primary variables of interest
• Clear definition of study population(s)
• Clearly stated null and alternative hypotheses
• Complete description of statistical methods that will be used to evaluate the data for primary and secondary aims. For protocols that employ statistical tests, the protocol must document the number of sides (e.g., one-sided vs. two sided) and type I error to be used.
• Statistical justification for the requested sample size. Power calculations must be included when statistical tests will be used to evaluate a primary hypothesis.
• Where appropriate, include early stopping rules that will be used to improve cost efficiency and protect valuable biosample resources.

Specimens requested

Data Request = select if this request is for data only

Tissue or Biopsy only (no blood) = select if not interested in blood collection

Special Studies = select for blood collection

* must provide value

Data Request Tissue or Biopsy only (no blood) Special Studies (blood collection)

Specimens requested

Data Request = select if this request is for data only

Specimen Processing = select if this request is only for processing specimens you will deliver to the BRF

* must provide value

Tissue Blood Bodily Fluids Data Request Specimen Processing

Does blood need to be matched to the time of diagnosis?

* must provide value

Yes

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Specify interval for matched blood:

* must provide value

Is there an order in EPIC for blood draw on this date?

* must provide value

Yes No

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Request BRF Phlebotomy service

Phlebotomy service needed

Cancer Primary Site

Bladder

Breast

Colon

Endometrium

Head, face or neck

Kidney

Liver

Lung

Ovary

Pancreas

Prostate

Skin

Stomach

Thyroid gland

Uterus

Other

Please specify Other

* must provide value

Tissue Type

* must provide value

Tumor Normal Metastatic

Histologic subtype

Number of Tumor cases

Number of Normal cases

Number of Metastatic cases

Preserve types for requested specimens

Snap Frozen Tissue

Fresh Tissue / Blood

FFPE Sections

FFPE Block (limited availability)

H&E Slides

Digital H&E Slides

TMA Sections

Custom TMA block

PDX Models (Patient-derived Xenograft)

Please visit our PDX Query Tool to view available PDX models and request a vial.

View availability:

Number of FFPE sections

FFPE slide thickness in µm

5 µm 10 µm Other

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FFPE Sections - charged or uncharged slides

* must provide value

Charged (for staining)

Uncharged (for DNA/RNA)

TMA Sections - charged or uncharged slides

* must provide value

Charged (for staining)

Uncharged (for DNA/RNA)

Do you want FFPE scrolls instead of slides?

* must provide value

Yes

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Number of pieces (~100 mg weight) of snap frozen

1 2 3 (limited availability)

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Number of H&E slides

Number of Tissue microarray sections

Where are the tissues for the custom TMA sourced from?

BRF-provided tissue

Investigator-provided tissue

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Please provide name of the Pathologist who will review FFPE blocks and TMA

Please describe custom TMA map:
1) How many cores will be in the TMA?
2) Will cores be in duplicate?
3) What tissue will be used for controls?
4) How many cores from controls?

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Blood products requested:

Serum

ACD Plasma

EDTA Plasma (double-spun)

Buffy Coat

Frozen Whole blood

Fresh Whole Blood

PBMCs / Viable Lymphocytes (cell count not available)

Bone Marrow (viable mononuclear cells)

DNA

Other

Quantity fresh whole blood

10mL Whole Blood

20mL Whole Blood

30mL Whole Blood

Other

Please specify Other

* must provide value

Blood Other quantity

Serum quantity

DNA quantity

Fresh whole blood products requested:

Serum Tube [Red Top Tube]

ACD Tube [Yellow Top Tube]

EDTA Tube [Lavender Top Tube] (double-spun)

Heparin Tube [Green Top Tube]

CellSave Tube

CPT Tube (for PBMCs)

Streck Tube

Other

DNA concentration

ACD Plasma quantity (2.0 ml aliquots)

EDTA Plasma quantity (2.0 ml aliquots)

Plasma quantity

Buffy coat blood quantity (2.0 ml aliquots)

Frozen whole blood quantity (1.0 ml aliquots)

PBMCs / Viable Lymphocytes quantity
Cell count not provided

Blood Other quantity

Please specify Other

Whole blood (2.0 ml aliquots)

Buffy coat (1.0 ml aliquots)

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Bodily fluids requested:

Pleural Fluid

Ascites Fluid

Urine

Other

Please specify Other

* must provide value

Please select standard data elements needed for this request

Demographics (Biological Sex, Race, Ethnicity, Year of Death / Year of Last Follow-up)

Specimen data (Age at Collection, Tumor Type, Tissue Site, Metastasis Site, Treatment Naive Status, Genetic Testing consent status)

Diagnosis (Age at Diagnosis, Tumor Site, Histology, Stage and Grade when available, Recurrence data)

Basic treatment data (Treatment modality, Day intervals between diagnosis and treatment)

Will you need additional data elements abstracted for this research?
This may require additional data abstraction charges and additional time to abstract data

Yes No

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Please select additional data elements needed for this research

BMI

Tobacco History (pack years)

Medication data/Chemotherapy drugs

Germline genetic testing results and Family history of cancer (when available)

Health history questionnaire data (when available)

Tumor Markers and Somatic Genetic Testing (when available)

Redacted Pathology Report

Other Not Listed

Please provide additional details about data elements needed for this research

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Controls needed (provide selection criteria):

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