Application Form Scheduled Collection

A-Principal Investigator (Please include a copy of CV)
Name
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Institution
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Address
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Telephone
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Mobile No
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Email ID
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Upload CV - Project Investigator
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B- Project Collaborators
1-Name, Designation, Mobile, Email
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2-Name(2), Designation, Mobile, Email
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3-Name(3), Designation, Mobile, Email
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C- Research Proposal
Attach a single A4 page providing the title and a succinct summary of the research project (aims, technical methods and estimated project duration) for which National Liver Disease Biobank materials are requested.
Attach
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D-Information relating to Institutional Review Board Approval (Please enclose a copy of the IRB Approval Letter)
Project Title
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Approval IRB Ref
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Expiry Date(*)
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Estimated Project Duration
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Remarks (if any)
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E- Sample Collection/ Deposition Average size of tissue released is 5 mm3; whole blood released: 1.5 ml (1 tube); serum released: 0.5ml (1 tube) and plasma 0.5 ml unless specified.
No. of tissues requested
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Do you need?
Frozen Tissue(*)
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Number of tissues requested
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FFPE Block
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Number of tissues requested
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Do you need any of the following?
Matched Normal Tissues
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Matched Whole blood
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Matched Plasma
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Matched Serum
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Urine
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Faecal
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Buccal Swab
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If you need Biosamples other than the listed names, please specify
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Any special protocol for biospecimen collection
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Please list any additional information required
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F- Funding Agency
Source of funding
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Cost of Project (in Rs.)
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Approved Start Date(*)
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End Date(*)
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Conditions for use of NLDB
We the undersigned hereby accept the release of and take control and possession over the Biobank Material (“Materials”) identified in section E, upon the following terms:
1. We understand that all Materials are not tested for or treated against viruses, bacteria, other infectious agents, or biohazards, and all Materials should be handled as if potentially infectious. Recipient(s) and Recipient Institution(s) agree to assume all responsibility and risks for the safe and proper receipt, handling, transportation, storage, use and disposal of the Materials, and for informing and training personnel in the responsibilities and risks thereof.

2. All Materials are provided without warranty or merchantability, satisfactory quality, fitness for a particular purpose, compliance with description, or any other warranty, express or implied. NLDB accepts no responsibility for any injury (including death), damages or loss that may arise either directly or indirectly from their receipt, handling, transportation, storage, use and/or disposal.

3. We agree to use the Materials only by our authorized research teams and shall not release any Materials to third parties or unauthorized employees, except with NLDB’s prior written agreement and will not participate in the commercial exploitation arising from the research or receive any benefit there from unless we have obtained prior written consent of NLDB, which if granted may be subject to such terms and conditions which may be imposed by NLDB.

4. We will not attempt to contact any person whose tissue or tissue derivatives are comprised in the Materials and/or his/her relatives, whether regarding the results of any aspect of the research project or otherwise, or to obtain the identity of such person.

5. We further agree to acknowledge the contribution of NLDB in all publications.

6. We agree and undertake not to retain the Materials and/or their biological derivatives and shall completely destroy the Materials and/or their biological derivatives upon completion of the research unless we furnish justification to NLDB and relevant Institutional Review Boards and such approvals, which may include further terms and conditions, have been obtained in writing prior to the completion. We note that fresh application must be submitted before the Materials and/or their biological derivatives can be used for any research other than that approved in this application.

7. We agree to be bound by all covenants, terms and obligations in this Agreement jointly and severally.

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