Biologic Specimen and Data Repository Information Coordinating Center
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Specimen Request Form

* = Required Field

Request Identifier

Create a nickname for your reference.

Requestor Information

Support Information

Specimen Shipping Information

Note: All specimens will be shipped to the above address. Specimens cannot be shipped to a post office box.

Request Details

Hold down "Control", or "Command" on a Mac, to select more than one.
Approximate count of specimens required for your study.
Please include units.
Please include units.
Describe any additional requirements pertaining to the biospecimens themselves, such as anticoagulant used, additives, preservatives, etc.
Describe the characteristics of the subjects to be searched for available specimens. Criteria might include gender, age, disease status, genotype, etc. Be as specific as possible.
A brief overview of your research needs.
Provide the research protocol background, objectives and hypothesis.
Describe the assay(s) to be performed and include any test volume requirements.
Describe the assay kit(s)/platform(s) to be used, if applicable.
Also describe your intended use of covariates from study datasets, if applicable.
A "Yes" response defines this as a "Commercial Purpose" request.
Were you an investigator with the original (parent) study(ies) referenced in this request?