Biospecimen Request Form

Please complete this form with all required and accurate information to ensure timely review and processing of your biospecimen request. Incomplete or missing details may result in delays or the need for additional clarification.

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Organization Name

Department

Requestor Name *

First

Last

Email *

Project Details

Indication / Disease Area

Intended Use of Biospecimens (check all that apply)

• Biomarker Discovery
• Assay Development / Validation
• Exploratory Research
• Research Use Only (RUO)
• Commercial Use
• Other (Specify)

Department that that

If Other, Specify it Here

Specimen Type (check all that apply)

• Blood
• PBMC
• Plasma
• Serum
• Bone marrow
• FFPE
• Fresh Frozen
• Others (Specify)

If Other, Specify it Here

Tissue Details (if applicable)

Tumor Type

• Primary
• Metastatic

Tumor Site

Matched Normal Tissue Required

• Yes
• No

Number of Samples / Vials Requested

Minimum Volume / Weight per Sample

Number of Slides, if FFPE

Section Thickness (um)

Required Annotations (check all that apply)

• Age
• Sex
• Diagnosis
• Pathology Report
• Stage / Grade
• Treatment
• Treatment Response
• Outcome / Survival Data
• Genomic Data (Specify Below)
• Other (Specify Below)

If Genomic Data or Other, Specify it Here

Informed Consent RequiredYesNoNot Sure

Data De-identification RequiredYesNoNot Sure

Requested Delivery Date

Shipping Temperature

• Ambient Temperature
• 4C
• -20C
• -80C / Dry Ice

Additional Requirements / Notes

AUTHORIZATION

I confirm that the above information is accurate and that all requested biospecimens will be used in accordance with applicable ethical, legal, and regulatory requirements.

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