Application Form - Ontario Tumour Bank

Principal Investigator Information

Principal Investigator Name(Required)

First Last

Principal Investigator Phone(Required)

Principal Investigator Email(Required)

Institution / Organization(Required)

Name

Department (if applicable)

Name

Principal Investigator Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Principal Investigator Short CV(Required)

Drop files here or

Accepted file types: doc, docx, pdf, Max. file size: 8 MB, Max. files: 1.

Please upload a short CV only (in standard scientific grant format).

Shipping & Billing

Shipping Address(Required)

Same as Principal Investigator Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Shipping Contact Name(Required)

First Last

Shipping Contact Phone(Required)

Shipping Contact Email(Required)

Billing Address(Required)

Same as Principal Investigator Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Billing Contact Name(Required)

First Last

Billing Contact Phone(Required)

Billing Contact Email(Required)

FedEx Shipping Account Number(Required)

All shipping fees will be billed directly to FedEx account number at time of shipment(s).

Purchase Order Number (if available)

Upon approval, a Purchase Order (PO) must be issued by recipient in the amount of the Estimate Total.

Tax ID Number (for US / international only)

Required for US / international orders.

Sample Request

Disease Site(s)(Required)

Number of Cases (per disease site)(Required)

If multiple disease sites are requested, please indicate number of cases per disease site (e.g., 10 colorectal and 10 lung).

Inclusion / Exclusion Criteria (if applicable)

If multiple disease sites are requested, please indicate inclusion/exclusion criteria per disease site (e.g., treatment-naive colorectal and neoadjuvant chemotherapy treated lung).

Sample Types(Required)

Number of Vials per Case(Required)

If multiple sample types are requested, please indicate number of vials per case for each sample type (e.g., 1 frozen tumour and 1 buffy coat).

Sample Requirements / Processing (if applicable)

If multiple sample types are requested, please indicate sample requirements / processing for each sample type (e.g., 50 mg aliquot of frozen tissue and 50 uL aliquot of buffy coat).

Frozen Tumour – Number of vials(Required)

Frozen Normal Adjacent – Number of vials(Required)

Frozen Plasma – Number of vials(Required)

Frozen Buffy Coat – Number of vials(Required)

Frozen Cell-Free Plasma – Number of vials(Required)

Type of FFPE sample(Required)

Slides

Wax sections / Curls

Tissue Microarray

Number of slides per block/case(Required)

Slide – Thickness, staining, baking time and temperature, and other preparation details(Required)

Number of sections per block/case(Required)

Section – Thickness, and other preparation details(Required)

Number of tissue cores(Required)

Number of tissue core replicates(Required)

Tissue Microarray(Required)

Whole Block

TMA Sections

DNA and/or RNA extraction source(Required)

Frozen Tumour

Frozen Normal Adjacent

FFPE Tumour

FFPE Normal Adjacent

Plasma

Buffy Coat

Health Record Data

Basic data:
– Donor demographic information (e.g., age, sex, vital status)
– Histology and diagnosis details (e.g., histologic type, stage, grade)
– Sample collection details

Full: basic data supplemented with information below
– Patient history (e.g., prior cancers, smoking, risk factors)
– Family history of cancer
– Surgery (e.g., procedure types and dates) *
– Radiotherapy (e.g., intent, start and date dates, dose) *
– Toxicities relating to treatment *
– Systemic therapy (e.g., intent, start and end dates, regimen and agent details)
– Outcome/follow-up (e.g., progression/recurrence status, disease-free period)
* Available for cases collected after 2009

Health record data required(Required)

Basic

Full

Other

Other(Required)

Study Details

Study Title(Required)

Name

Research Ethics Board(Required)

Name

Date of Research Ethics Expiry (if applicable)

Research Ethics Certificate of Approval / Exemption(Required)

Drop files here or

Accepted file types: doc, docx, pdf, Max. file size: 8 MB, Max. files: 1.

Please upload certificate / letter of approval or exemption from your research ethics board (REB/IRB).

Study Protocol(Required)

Drop files here or

Accepted file types: doc, docx, pdf, Max. file size: 8 MB, Max. files: 1.

Please upload study protocol as reviewed by your research ethics board (REB/IRB).

Funding Source(Required)

Grant

Venture Capital

Other

Name of Funding Source(Required)

Will any collaborators or third parties process and/or analyze samples and/or data?(Required)

Yes (Note: A separate Collaborator/Service Provider Agreement will need to executed)

Principal Investigator Signature

I have read and certify that all the information provided in this form, together with any other information that I may provide, is true and accurate to the best of my knowledge. I agree that a signed Material Transfer Agreement between OICR and my Institution / Organization is in place prior to the release of any samples and/or data.

Typed Name as Signature(Required)

Date of Signature(Required)