Application Form - Ontario Tumour Bank

Principal Investigator Information

Principal Investigator(Required)

Prefix First Last

Principal Investigator Address(Required)

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

Principal Investigator short CV(Required)

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

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

Shipping & Billing

Shipping Address(Required)

Same as Principal Investigator Address

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

Laboratory Contact(Required)

First Last

Laboratory Contact Phone(Required)

Laboratory Contact Email(Required)

Billing Address(Required)

Same as Principal Investigator Address

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

Billing Contact Phone(Required)

Billing Contact Email(Required)

Shipping Courier

FedEx

Purolator

UPS

Other

Tax ID #

Required for international and U.S. orders.

Shipping Delivery Instructions

(e.g., express delivery)

Sample Request

Disease site(s)(Required)

Number of cases(Required)

Sample Types(Required)

Selecting an option gives additional fields to fill in.

Frozen Tumour – Number of vials/case(Required)

~50 mg per vial

Frozen Normal Adjacent – Number of vials/case(Required)

~50 mg per vial

Frozen Plasma – Number of vials/case(Required)

~1 mL per vial

Frozen Buffy Coat – Number of vials/case(Required)

~250 uL per vial

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

~1 mL per vial

Type of FFPE sample(Required)

Slides

Wax sections / Curls

Tissue Microarray

Number of slides/case(Required)

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

Number of sections/case(Required)

Section – Thickness, and other preparation details(Required)

Number of tissue cores/case(Required)

Tissue Microarray(Required)

Whole block

TMA Sections

Custom Prospective Tissue & Blood – details on minimum weight/volume, processing, storage, etc.(Required)

Clinical 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

Clinical data required(Required)

Basic

Full

Other data requested

Study Details

Study Title(Required)

Current status of REB/IRB review(Required)

Approved

Exempt

In progress

Date of ethics approval expiry(Required)

Research Ethics review (approval or exemption) and Research Protocol/Proposal(Required)

Drop files here or

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

Please elaborate on your REB/IRB review in progress.(Required)

Funding Source(Required)

Grant Number

Approval Date

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

Yes (note they will need to sign a Collaborator Agreement)

Research Proposal
Maximum 2 pages. Please include:

Objectives and significance of project – explain and justify:
– Background information
– Hypothesis and aims
– Inclusion/exclusion criteria for tissue (include based on gender, age, etc.)
– The number of samples required for the overall project and the number of samples required from the OTB (provide evidence of power calculations)
– Clinical data required (see list in previous section)
– Any potential conflicts of interest in this study involving any of the investigators

A brief description of methods:
– Technical approach
– Types of assays, markers to be measured, etc.
– In the processing of data, will there be linkages to other databases? If yes, please describe the other databases, and comment on the possibility of identification of the source.

The research proposal may be typed out or attached as a file below.

Research Proposal text

Mandatory if you are not uploading the proposal.

Research Proposal upload

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

Mandatory if you are not typing out the proposal in the text box.

Lay Language Summary(Required)

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 Research Organization is in place prior to the release of any tissue and data.

Typed Name as Signature(Required)

Today's Date(Required)