Application Form - Ontario Tumour Bank

Thank you for taking the time to complete this application form.

You may save your progress at any point by clicking the “Save and Continue” button at the bottom of the page. You will then be asked to provide an email address where a unique link will be sent to you. This link allows you to return to your form and continue editing from where you last left off. It can also be shared with collaborators, and will remain active for 30 days.

Please note that this is NOT an initial inquiry form. It should only be completed after meeting with OTB’s Senior Client Coordinator. If you wish to submit an initial inquiry or request samples, please use the Sample Request Form (this link will open in a new tab).

Principal Investigator (On Research Ethics Approval)

Name(Required)

First Last

Email(Required)

Phone Number(Required)

Address(Required)

Street Address Department and Institution City State / Province / Region ZIP / Postal Code Country

Internal Collaborators (Co-PI or other study contacts):

Sample Request

Disease Sites(Required)

Please list all sample disease sites of interest

Inclusion/Exclusion Criteria:(Required)

Number of cases(Required)

Sample Types(Required)

Sample Processing

Optional samples and services

DNA

RNA

Tissue Sections (Slides/Curls)

Tissue Microarray (TMA)

Other

Please list the quantity per case for each sample type and processing service selected:(Required)

For example: Frozen tumour – 2 vials per case, Buffy coat – DNA extracted (quantity)

Tissue Sections – Please list the required number of sections per block, thickness per section (5 µm standard), and whether the sections should be stained/unstained, baked/unbaked, and charged/uncharged:(Required)

TMA – Please detail the required number of cores per block and core sizes (0.6 mm standard):(Required)

Please describe the other sample types or sample processing required for your request and their corresponding quantities:(Required)

Clinical data required(Required)

Basic

Full

Other

See here for more details (this link will open in a new tab)

Other data requested

Study Details

Current status of REB/IRB review(Required)

Approved

Exempt

In progress (will provide once received)

Please Attach Research Ethics Review Letter/Certificate of Approval or Exemption(Required)

Drop files here or

Accepted file types: doc, docx, pdf, Max. file size: 10 MB.

Please Attach Study Protocol (as submitted to REB/IRB)(Required)

Accepted file types: pdf, doc, docx, Max. file size: 2 MB.

Please Attach Principal Investigator Short CV(Required)

Accepted file types: doc, docx, pdf, Max. file size: 2 MB.

Source of Funding:(Required)

Please List External Collaborators / Service Providers (who will process or analyze samples and/or data):

Billing Information

Contact Information including name, email, and phone number same as PI?(Required)

Yes

Name(Required)

First Last

Email(Required)

Phone(Required)

Billing Address(Required)

Same as Principal Investigator Address

Street Address Department and Institution City State / Province / Region ZIP / Postal Code Country

Shipping Information

Tax ID (for international orders)

Preferred Courier(Required)

FedEx

Other

Courier Account Number(Required)

Special Delivery Instructions:

Contact Information including name, email, and phone number same as PI for shipping address?(Required)

Yes

Name(Required)

First Last

Email(Required)

Phone(Required)

Shipping Address(Required)

Same as Principal Investigator Address

Street Address Department and Institution City State / Province / Region ZIP / Postal Code Country

How did you hear about the Ontario Tumour Bank?

Other

Principal Investigator Approval

Typed Name as Signature(Required)

Today's Date(Required)