TCP Enrollment Form
UNIVERSITY OF MICHIGAN COMPREHENSIVE CANCER CENTER
APPLICATION FOR ENROLLMENT IN THE
TISSUE PROCUREMENT CORE
Name and Degree(s) of Principal Investigator:
Office Address (including campus zip/box no.):
Phone: FAX number: e-mail address:
Are you a member of the Comprehensive Cancer Center?
Title of Project:
(If there is a specific peer-reviewed, funded project for which this tissue will be utilized, please provide grant number:)
Contact Person for collection: Phone/pager:
- Organ(s) or Site(s):
- Type of Tissue (neoplastic, normal, both, other):
- Is there a minimum amount of tissue required per specimen (approximate size or weight)?
Note: If the minimum amount is not available from a given specimen, tissue will not be procured. Therefore, please be as specific as possible, rather than requesting “as much as possible”.
- Any special patient characteristics (age, sex, etc.) or limiting characteristics:
- Mode of procurement and collection: frozen in tube, frozen in OCT, fresh in tube, fresh in media, other (please be as specific as possible). Note: Confirmation with the Tissue Procurement Core technologist (see below) after Approval for Services is issued is required.
- Total number of specimens desired:
- Desired time period of collection:
- Do you require a copy of the pathology report corresponding to the procured tissue?
- Do you require being able to identify the patient from whom the tissue was derived?__________
- If patient identification is requested, please provide an active IRB-approved number:_________
I have read the attached Tissue Procurement Core Frequently Asked Questions and agree to comply with the guidelines as stated there:
Submit this application to: Thomas J. Giordano, M.D., Ph.D.
Department of Pathology
1150 W. Medical Center Drive C570 MSRB-2 5669
Or fax to: 615-0688
Notification of approval (“Approval for Services of the Tissue Procurement Core”) will be provided as soon as possible. Procurement of tissue samples cannot begin until IRB approval is obtained and a copy provided to the above address.
Questions regarding tissue procurement should be directed to the Tissue Procurement Core technologists (Deborah Postiff, 4-8025, page #8952, email@example.com, Justin Reagan firstname.lastname@example.org ) or to Dr. Giordano at Giordano@umich.edu Approval is subject to renewal.