Tissue Bank– In The Department of Pathology

Service Request Form

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

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

Contact Person:*

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
PRMS approval has been obtained (for clinical trials)
PRMS approval is pending (for clinical trials)

IRB Status:* Obtained Exemption Pending

 

Stanford Medicine Resources:

Footer Links: