BMC Pathology Clinical Trials and Research Requests Supplemental Information Form

BMC Pathology Clinical Trials and Research Requests Supplemental Information Form

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Thank you for your recent request to BMC Pathology. In order for BMC Pathology to process your request, a few additional details are needed.

Please complete the information below. (Note: If you are requesting tissue from multiple specimens, only one (1) form per IRB protocol needs to be completed.)

Please contact the Clinical Trials Office at CTO@bmc.org first and register your study in VELOS: https://www.bmc.org/sites/default/files/Research/VelosCTUserAccessRequestForm.pdf

Date submitted:

Requester Contact Information

Name of the requester

Email

Phone number

Principal Investigator Contact Information

PI Name:

Email

Phone number

Funding Information

Source of funding

DepartmentalFederal GovernmentIndustryInvestigatorFoundationCollaboration/ JointlyOther

If Other, please specify:

Funding cost center

Grant office

If selects "Other/external", please indicate

IRB (if applicable)

Is BMC a participating site on this protocol?

YesNoEnrolling both BMC and non-BMC patients

If selects "Yes", state BMC Site PI:

Is your team collaborating with BMC Pathologists?

If selects "Yes", please list all the name of BMC Pathologists

Study description

Provide a brief description of the study, including tissue type & intended use. Include Accession #, patient first and last name, MRN and block code if known, priority, anatomic site, and minimum requirements

IF GREATER THAN 50 MICRONS OF TISSUE IS NEEDED, YOU MUST JUSTIFY IN THE TEXT BELOW:

Study accrual goal (anticipated total number of patients/cases):

Categorize the research study into one of the following four (4) categories:

Group A

Patient treatment in the context of a clinical trialClinical trial correlative studies

Group B

Ongoing retrospective study/case seriesTissue collection for banking/repository

Please upload copies of IRB approval/continuing review form (listing expiration date)

Please upload copies signed patient consent(s) for use of tissue

Was the protocol approved with waiver of patient consent?

Please upload copies signed patient consent(s) for use of tissue

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