Companion Animal Tumour Sample Bank Sample Application
Study Title:
Principle Investigator
Name and Title
Department and Institution
Address
Phone Email
Laboratory Shipping Address
Shipping Contact
Shipping Address
Phone Email
Courier Name and Account #
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Samples Requested
Disease(s) Number of cases
canine feline both
Type of sample (1 vial per sample type per case unless otherwise requested and
approved):
fresh frozen tumour fresh frozen normal
tumour in RNAlater normal in RNAlater
fresh frozen plasma fresh frozen serum
fresh frozen urine tissue sections FFPE
other cryosection
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.
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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
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