> ![](media/image1.png)

**MEMORANDUM**

> To: Principal Investigator
>
> From: NCI/CCR/Laboratory of Pathology
>
> Tissue Resource Committee
>
> Subject: Request for Human Biological Materials for Research
>
> Thank you for your inquiry into Laboratory of Pathology for Human
> Biological Materials. Please fill out the attached request form. Your
> proposed experiment must be covered either by an existing IRB-approved
> protocol or exemption from the requirement for IRB review. You can
> contact the Office of Human Subjects Research (OHSR) for the exemption
> form or refer to web site: <http://ohsr.od.nih.gov/>
>
> Biological material from autopsy cases or deceased patients does not
> require OHSR exemption or IRB approval. Release of biological material
> from deceased patients without an OHSR exemption requires
> certification or proof that the patient has expired.
>
> Where necessary include information on IRB approval or exemption,
> protocol requirements, and patient name, CC number, pathology number,
> and block number if known. Support requests should be submitted to
> Mrs. Susan Gantz, Bldg 10, Room 2N212. Requests will be reviewed by
> the LP Tissue Resource Committee and forwarded to the Laboratory of
> Pathology Service Chief as quickly as possible.

###### Materials cannot be released unless sufficient diagnostic material is available for NIH archives. For those requests where adequate material is remaining, upon receipt of a completed form, the NCI Laboratory of Pathology, Histology section will oversee the preparation of the material. If a request cannot be accommodated based on the workload, it will be sent out to a reference laboratory chosen by NCI/LP at the requestor\'s expense. Current outside laboratory costs run from \$2.95 per untreated, unstained slide to \$3.35 per gelatin, lysine, or silanated slides and \$7.35 per hematoxylin and eosin stained slides. Please include your CAN number to cover the cost of such request. 

###### ![](media/image2.png)

> **NCI LABORATORY OF PATHOLOGY**
>
> **INTRAMURAL REQUEST FOR HUMAN BIOLOGICAL MATERIALS FOR RESEARCH
> PURPOSES**

####### PRINCIPAL INVESTIGATOR INFORMATION

> **Principal Investigator (please print name legibly):
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**
>
> **Institute: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Branch:
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_Building: \_\_\_\_\_ Room:
> \_\_\_\_\_\_\_\_\_**
>
> **Phone: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Page:
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Fax: \_\_\_\_\_\_\_\_\_\_\_\_\_**
>
> **E-mail:
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

######## Alternate Contact Information: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ 

> **Alternate Phone: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Page:
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Fax: \_\_\_\_\_\_\_\_\_\_\_\_\_**
>
> **E-mail:
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**
>
> **CAN number:
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

####### 

####### DESCRIPTION OF RESOURCE NEEDS

> **Type (must check)** \_\_ Linked (identifiable) \_\_Anonymized \_\_
> Autopsy \_\_Deceased
>
> **Tissue source requested:**
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_ Normal tissue
>
> \_\_ Abnormal tissue. Indicate key diagnostic terminology for database
> search.
>
> **Service:** \_\_ Autopsy \_\_ Cytogenetics \_\_ Cytopathology \_\_
> Flow cytometry
>
> \_\_ Hematopathology \_\_ Immunohistochemistry \_\_ Laser capture
> microdissection
>
> \_\_ Molecular diagnostics \_\_ Surgical Pathology \_\_ Other
> (specify): \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> **Recuts:** \_\_ Recuts only (please attach list with patient name,
> NIH patient number, path number, block #)
>
> \_\_ Recuts with pathology review (attach list )
>
> **Tissue Type (circle all that apply):** Fresh Frozen Paraffin Autopsy
> Cytology Other:\_\_\_\_\_\_\_\_\_\_\_\_
>
> **Circle recut slide type :** Regular/untreated Gelatin Poly-L-Lysine
> Silanated Other/specify: \_\_\_\_\_\_\_
>
> **\# of slide recuts: \_\_\_\_\_\_\_ \_\_\_ check if recuts should be
> made using Rnase precautions.**
>
> **Other:
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**
>
> ***NOTE: Materials cannot be released unless sufficient diagnostic
> material is available for NIH archives.***

**INTENDED USE & METHODOLOGY (Attach additional pages if necessary)**

> **Please include a list of any special requirements or exclusions, and
> include and expiration date of request if applicable.**

####### 

####### OSHR EXEMPTION FORM or IRB APPROVAL NUMBER MUST BE PROVIDED

##### **Attach OHSR Exemption Form or provide IRB Protocol #: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

##### *Note: An OSHR exemption is not required for Autopsy material. For release of material from non-living patients, please attach certification or proof that the patient has expired.*

# 

# **CERTIFICATION BY PRINCIPAL INVESTIGATOR**

> The approval provided covers both the protocol and patient-executed
> consent, and the research proposed is specified within the approved
> protocol and consent or IRB waiver of consent.
>
> **Signature of Principal Investigator of the specified protocol or
> waiver:**
>
> **X
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_Date:
> \_\_\_\_\_\_\_\_\_\_**

#### \*\*\* INCOMPLETE FORMS WILL BE RETURNED TO PRINCIPAL INVESTIGATOR \*\*\*

> For more information contact: Kevin Nellis, MT(ASCP), Clinical Lab
> Manager
>
> \(301\) 594-9532 or NIH page 104-4613 or e-mail:
> <nellisk@mail.nih.gov>
>
> Return form and attachments to: Laboratory of Pathology, Tissue
> Resource Committee
>
> 10 Center Drive, Room 10/2A33
>
> Attn: Ms. Susan Gantz (<gantzs@pop.nci.nih.gov>)