Clinical data required
Basic patient demographics (age, breed, sex)
Histological diagnosis and pathology report
Details of therapy
Outcome/follow-up
Other
Details of Study:
Duration of project and proposed start date
Funding status
Funded Source
Funding Applied for Source
Attach a one-page description of the study, including Background Information, Rationale,
Objectives/Aims, Basic Methods, and Justification for Sample Access.
•••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••
I agree that the description of the planned study is an accurate account of planned use
for the material obtained from the ICCI CATSB. Yes
If this application is approved, an MTA will be executed by both parties. Agreed
Signature of Principle Investigator
Date