Tissue Procurement and DistributionRequest Form

Requestor Information
Name: Email:
Mailing Address:
Phone #:Fax #:
Project Information
PI:
Affiliation (e.g. Lilly, IU, NIH):
Account # (for billing purposes):
Project Title:
IRB #:
Donor criteriaAnnotation required
  Age:  Gender:

Race:

(please fill in)
Tissue Information
Solid Tissue Anatomic Site:
Diagnosis (Tumor):
Diagnosis (Normal):
Diagnosis (Benign):
(check all that apply)
  # of SamplesMin. VolFixedFrozenFresh


Matched Pairs
(T+N;T+B;B+N)		 Tumor Needed:
Normal Needed:
Benign Needed:
(check all that apply)
  # of SamplesMin. VolFixedFrozenFresh


Unmatched Pairs
(stand-alone samples)		 Tumor Needed:
Normal Needed:
Benign Needed:

Slides cut from blocks can be provided at an additional cost


I have completed IU or other approved Biosafety Training on handling human tissue and blood.

I have passed the Human Subjects Protection Course.

I have received at least 2 inoculations in the vaccination series for Hepatitis B.

Documentation for completion of the above requirements is not required at this time but may be required
in the future.