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    Liver Biorepository Sample Request Form

    If you have problems using the Word document listed above, provide us with the information below.



    Date:

    Investigator Affiliation and Title:

    Study Title

    Abstract / Introduction to the Research (1-2 paragraphs, in layman’s language)

    The Scientific framework of the Research project (up to 2 pages of detail showing the scientific rationale for the work and justifying the need for access to the requested samples)

    Funded or Unfunded Research (if funded, include the funding source)

    Is the study approved by the CPMC IRB?
    (Supply a copy of the IRB approved protocol and approval letter with this application. If an external IRB approves the work at the receiving institution as well as having CPMC IRB approval supply copies of both IRB approvals.)

    Yes: CPMC IRB Approved Protocol Number: __________
    Study Protocol Title:

    No: Title of your local IRB:
    Study Protocol Title:

    Will there be Commercial use?

    What EXACTLY are you asking for? (include specific information about the need for data associated with each sample, if any)

    How many samples are you asking for?

    Please justify the number of samples requested. For example, what power will you have to detect the effect or difference that you hypothesize?

    How much per sample are you asking for? (volume; mass etc., as applicable)

    Acknowledgements in publications:

    A condition of release of samples from the Biorepository for your use is that you acknowledge the Biorepository in any publications and presentations, whether internal or external. How do you plan to acknowledge your use of any samples received in presentations and publications? (supply examples of previous acknowledgements or references, as available, or draft acknowledgment text):

    Do you agree NOT to transfer samples to a third party? :
    (if you are operating under a CPMC approved protocol but working with an external researcher please supply a copy of the Material Transfer Agreement)

    Do you agree NOT to attempt to identify the research subject(s) unless we have provided you with identified samples, your research requires contact with the subject, and that is explicitly stated in your study protocol? :

    When this form is completed please send, via email, to biorepository@sutterhealth.org along with copies (pdf preferred) of any requested supporting documents.