UMMC Biobank Specimen Request

Principal Investigator Information

First Name *

Last Name *

Institution * UMMC Academic Institution Commercial

Department *

Address 1 *

Address 2 *

Phone Number *

Fax Number *

Email Address *

Project Information

Project Title *

IRB Review * Approved Pending

IRB Number

IRB Expiration Date

Institutional Biosafety Committee Registration Approved Pending

Approval Date

Location/Room #

Funding Source *

Grant # *

Grant Start Date *

Grant End Date *

Account # to be charged

Activity #

Brief description of project

Protocol

Collaborators

Biospecimen Request

Anatomic Site *

Subtype (if known)

Diagnosis *

If Other, please explain

Processing *

Total number of specimens requested: *

If requesting FLUID biospecimens (max. 2ml/case): LIMITED QUANTITIES - APPROVAL FROM SUBCOMMITTEE Serum Plasma Buffy Coat

Serum Volume (in ml)

Plasma Volume (in ml)

Total number of specimens requested: *

Gender Male Female Any

Race

Additional chart review required Yes No

Review information requested

Principal Investigator Signature

Date