The Eunice Kennedy Shriver

NICHD Brain and Tissue Bank for Developmental Disorders

Department of Pediatrics, Room 13-013 BRB
University of Maryland, Baltimore
655 W. Baltimore St.
Baltimore, MD 21201
btbumab@umaryland.edu
(410)-706-1755 or (800)-847-1539
FAX: (410)-706-0020

Tissue Request Form

What We Need From You To Process Your Tissue Request

  1. Submit this completed Tissue Request Form to include contact information of the Principal Investigator and tissue requestor (if different).

  2. CV (NIH format) of Principal Investigator as a PDF sent to: btbumab@umaryland.edu.

  3. Supplemental material (if desired) - faxed to 410-706-0020 or emailed as a PDF to: btbumab@umaryland.edu.

The review process does not begin until we receive ALL necessary information.

Once your tissue request has been reviewed and approved, a Material Transfer Agreement must be completed and signed.

Form Directions

  • Fields marked with an ( * ) are must-fill fields.

  • To print this page (Print before you click the 'Submit form' button): Click the 'Printer friendly' link at the bottom of the page and then click the 'Print page' button in the upper right-hand corner.

  • Use the 'Submit form' button to submit the request for processing.

 
Today's Date:     
 

Principal Investigator

(For purposes of the NICHD Brain and Tissue Bank, the Principal Investigator is defined as the person whose name will appear on the Material Transfer Agreement and is recognized by their institution/university as the senior researcher in whose laboratory the research utilizing the tissue requested will be performed.)

 
Name*
Title (e.g. Dr., M.D.,Ph.D.)
Email*
FAX
Phone*
Department*
Institution*
Street Address 1*
Street Address 2
City*
State Zip Code  
Country
Province
Region
CODE
(city/province/region/country)

List the shipping address in the box if different from above.


Person/Investigator Submitting Tissue Request

(if different from Principal Investigator)


 
Name  
Email  
Phone  

YOUR RESEARCH PROJECT

 
Have you ever requested tissues from the Brain and Tissue Bank?
 

Title Of Your Project:

Source Of Funding:
(specify NIH institute, if appropriate)


Description/Goals:
All researchers are required to submit information in the box or as an ATTACHMENT that includes: Background, Specific Aims, Methods, and Preliminary Results. A recent publication by the researcher requesting tissue supporting the tissue request is helpful. Consider this to be a short version of a grant application. Typically, this section is between 1-3 pages in length. The box is limited to 12,000 spaces.



Upload and Email your Description/Goals:

To upload your DESCRIPTION/GOALS as a Word document (*.doc) or Adobe Acrobat document (*.pdf), see instructions below:
  1. Enter your Email address to the text box "FROM".
  2. Type any message in the message text box (optional).
  3. Click the "Browse..." button to upload file from your computer.
  4. Click the "Send Email & Upload File" button to submit.
From:
To:
Subject:
 
Message:
 
Filename:
 
 
 

Specifications of Tissue Required

 
Add special requirements for unaffected tissue at the end of this section.
Unaffected (Control) Tissue:

  FROZEN FIXED FRESH

# OF CASES

AMOUNT (size/mg/vol)

AGE LIMITS

SEX

RACE/ETHNICITY

PMI (Hours)

UMB#(s):
(if known)
Please do not use carriage returns. Separate entries with a comma and space. (e.g. 245, M1000M, 2333, 1099)

 

Tissue Requested:

 

Special Requirements:

 
 

Affected Tissue

Add special requirements for affected tissue at the end of this section.
Disorder Name:

  FROZEN FIXED FRESH

# OF CASES

AMOUNT (SIZE/MG/VOL)

AGE LIMITS

SEX

RACE/ETHNICITY

PMI (Hours)

UMB#(s):
(if known)
Please do not use carriage returns. Separate entries with a comma and space. (e.g. 245, M1000M, 2333, 1099)

 
Tissue Requested:

 
Special Requirements:

 
 
 
 

Tissue Request Summary Checklist

  Check if you have completed the following:
             Contact information, including that of the PI.
             Specific tissue requested.
             Description / Goals.
             Funding source for the planned research.
  If you will be submitting email attachments to btbumab@umaryland.edu, please check those that apply:
             CV (NIH format preferred) as PDF.
            Supplemental material (please list supplemental material):

             I understand that a completed and signed Material Transfer Agreement is required after the tissue request is reviewed and approved.

 

  Press to clear all form information and start over!

 

  Please press to print the form for your records

 

  Press here to send the information you have entered to the NICHD Brain and Tissue Bank.