BMC Pathology Clinical Trials and Research Requests Supplemental Information Form
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
Departmental
Federal Government
Industry
Investigator
Foundation
Collaboration/ Jointly
Other
If Other, please specify:
Funding cost center
Grant office
Please select...
BMC Research Finance
BMC Clinical Trial Office (CTO)
BU Office of Sponsored Programs
Other/External
If selects "Other/external", please indicate
IRB (if applicable)
Is BMC a participating site on this protocol?
Yes
No
Enrolling both BMC and non-BMC patients
If selects "Yes", state BMC Site PI:
Is your team collaborating with BMC Pathologists?
Please select...
Yes
No
If selects "Yes", please list all the name of BMC Pathologists
S
tudy 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 trial
Clinical trial correlative studies
Group B
Ongoing retrospective study/case series
Tissue 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 select...
Yes
No
Please upload copies
signed patient consent(s) for use of tissue
Contact Information
