The Scottish HPV Archive

Tissue Request Form

Please return completed request form to:

Dr Ramya Bhatia, HPV Research Group,

QMRI, 47 Little France Crescent

Edinburgh EH16 4TJ

Email: Tel: 0131 242 6625

SECTION A: INVESTIGATOR DETAILS

1.  Principal/Chief Investigator*

NAME:
TITLE/ROLE:
ADDRESS:
TELEPHONE NUMBER:
FAX NUMBER:
EMAIL ADDRESS:

2.  Requestor

*leave blank if the same as above

NAME:
TITLE/ROLE:
ADDRESS:
TELEPHONE NUMBER:
FAX NUMBER:
EMAIL ADDRESS:

3.  Collaborator

NAME:
TITLE/ROLE:
ADDRESS:
TELEPHONE NUMBER:
FAX NUMBER:
EMAIL ADDRESS:

Copy and paste this section for all other collaborators associated with request

SECTION B: PROJECT DETAILS

1.  Project details

A.  Project Title

B.  Please provide a lay summary of the project

C.  Please provide details of the project

Please provide the necessary title, background, aims, techniques to be used, result of pilot studies if relevant and expected benefits to HPV-related disease research. Alternatively, a protocol may be appended but must address these areas and should be limited 2 A4 pages, font 11.

2.  Funding

Do you have external grant funding associated with this request?
Funding source:
Duration of funding:

3.  Ethics

Has Research Ethics approval been sought for the research study?
If Yes, please provide a copy of the final outcome letter and state the reference number.
If No, please explain.

Note: The Scottish HPV Archive comes under the NRS Lothian Bioresource and has approval as generic REC approval as a research Tissue Bank provided by East of Scotland Research Ethics Service (Ref 15/ES/0094) for HPV related research on anonymised archive samples, but project approval may still be required.

4.  Experience of Group Performing Study

Please provide information to indicate experience of the group e.g. own publications relevant to this application, or preliminary data of related work carried out.

5.  What are your arrangements for ensuring security of samples and data?

6.  Specify and justify samples required

Please provide details of sample type, number and volume. Will this be related to a statistically powered study? If not please justify (e.g. Is this a pilot study?). This will be used to assess the value of the project against sample availability.

SECTION C: AGREEMENT / SIGNATURE

·  I /We undertake to acknowledge the provision of material/data from the Scottish HPV Archive, University of Edinburgh in any publication arising from the use of this material/data.
·  I /We undertake not to pass on this material/data to another user without permission from the Scottish HPV Archive, University of Edinburgh.
·  I /We accept that the material is supplied with the understanding that is used solely for the purposes of the research study outlined in the request.
·  I /We undertake to meet the costs of the transport arising from the fulfilment of this request.
·  I /We realise that the Archive does not test the samples that it procures for the presence of infectious agents other than HPV.
Signature: Date:
Fedex or other Courier account number:

FOR ARCHIVE USE ONLY

Date received:
Date reviewed:
Members of Steering Group involved in review:
Actions:
Signature of HPV Archive Manager:

Vers 1.14 Scottish HPV Archive Sample Request Form 11thAugust 2016