BTRF Application Form

BTRF Application Form

Principal Investigator: HIC #:
Mailing Address:
Phone: PIC#:

Contact Person (if differs from PI above) and PIC #:

Cancer Center Member? Yes No
Independent Funding? Yes No (If NO, please mail complete list of funding sources)
Account number to be billed (Ledger 5, preferred):

Names of collaborating investigators:

Sumary of Study:
Human Tissue Specimen Criteria
Anatomic site or tissue type:
Malignant Benign Normal Other

If malignant is selected, please specify:

Any malignant

OR Specify type of malignancy:

Is normal matching tissue required? Yes No If Available
Willl you accept tissue from patients previously treated with: Radiation Chemotherapy
Must specimen be sterile? Yes No As clean as possible
Note: Requirement for sterility may decrease yield of collected material, as some specimens will have to be handled non-aseptically for emergent pathologic diagnosis
Gender: Male Female Either
Tissue Source:

Surgical: Must be prepared with hours of removal OR

Surgical: Time contraint not applicable
Surgeon will harvest specimen for research prior to examination by Pathologist

* Surgeon(s) Requires informed patient consent of risk. Please mail HIC approved consent form.

Pathologist will process and provide specimen

* Pathologist(s)

Body Fluids containing tumor cells will be collected

*Type of Fluid

Patient Limitations: (i.e. age, race or other limiting characteristics): Please mail separately
Amount of tissue required (minimum to maximum size or dimension)
Estimated number of specimens to collect per year:
Requested starting date to receive tissue:
Preparation Specimens
(Form in which tissue needs to be provided to your laboratory):

Fresh. Indicate media requirements: Transport media Saline Dry

(If a preference for transport media please indicate i.e. RPMI, D-MEM):

Added Supplements: Antibiotics Fetal Calf Serum Fungizone

If supplements are needed indicate type and amount:

Delivery requirements (ice, room temp., etc.)

Fixed. Indicate fixative requirement (10% BNF, etc.)
Cryopreserved fresh viable cell suspension, sterile, in FBS/DMSO 5x106 cells or greater
Quick-frozen non-viable tissue, sterile, in one piece (1-5 mm diameter)/vial
Specimen Information Required: Anatomic sites of tissue, pathology's diagnosis, age, sex and race (if available) will be provided with all specimens.
Please mail separately
Please provide your email address to receive a copy of the submitted application for your records