Stanford School of Medicine
Tissue Bank– In The Department of Pathology

Service Request Form

* Required
Requester E-mail*:
Date: Assigned Project #:
Principal Investigator:
    Cancer Center Member    New/junior investigator
Department:
Contact Person:
Contact Information
  Address:
   
   
  Phone:
  Fax:
  E-mail:
Account to be charged:

Tissue Specimen Request

Anatomic site or tissue type:
Diagnosis: Tumor Normal
  Other
Processing: Frozen Fresh Fixed Paraffin-embedded
Tissue Source: Surgical Autopsy Either  
Gender: Male Female Either  
Number of specimens required:
Amount of tissue required:
H&E stained frozen section (no extra charge): Yes No
Date needed:

Serum Specimen Request

Diagnosis: Normal
  Cancer
  Other
Gender: Male Female Either
Number of specimens required:
Amount of serum required:
Date needed:

Patient Consent will be obtained by:

Tissue Bank
Investigator using Tissue Bank consent protocol
Investigator using project-specific consent protocol

Other Services:

 

H&E-stained frozen section

Quantity

 

Unstained frozen section

Quantity

 

Pathology report

Quantity

 

Review of slides

Quantity

Special Instructions:

Title of Project:
Study Phase: Assay development Pilot study Validation study
  Other  

Purpose of study (provide sufficient detail for assessment of scientific merit, and include justification for use of tissues requested):

Collaborators and nature of collaboration:

Location(s) of study:

Please check all that apply:

Project is currently funded.
         Funding source:
Project funding is peer-reviewed
IRB approval has been obtained
IRB-approved exemption has been obtained
IRB approval is pending
PRMS approval has been obtained (for clinical trials)
PRMS approval is pending (for clinical trials)

 

 

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