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BIOBANK REQUEST FORM Please fill out the information below. To use fillable form function, Save, then Open in Adobe Acrobat. If you have any questions please email: [email protected] PO/Study Number 1. Contact Information: Last Name: First Name: Middle Initial: Company Name: Address: City: State: Zip: Daytime Phone: Evening Phone: Fax: E-mail: Biospecimen Information: Check all that apply. 2. Consent Status Date Specimen Needed: Consented cases only Unconsented/waiver-of-consent acceptable 3. Biospecimen Disease-Status Tumor Benign Disease/lesion Normal Tumor/Normal Pair Other ______________________ ______________________ 4. For Cancer/Neoplastic Biospecimens Diagnosis/Diagnoses: _____________________, _________________________, _____________________ (see list provided, or enter a diagnosis not on the list) 5. For Normal Tissue & Benign Biospecimens If yes, please select: Immediately adjacent Organ/Site: __________________ Distal (at least 2 cm away) Associated with Tumor: yes no Any 6. Biospecimen Type 7. Data Solid tissue Pathology report Whole Blood Tumor Registry 'basic data set' Serum Requester's case report form Urine Other (please describe below) Other: __________________ __________________ 8. Biospecimen Format 9. Benign Disease/Lesions Formalin-fixed, Parafifin-embedded (FFPE) Adenoma Blocks Dysplasia Slides Hyperplasia Tissue Microarray (TMA) Breast Atypical ductal hyperplasia Inflammatory Frozen Crohn's disease OCT yes no Ulcerative colitis Mirrored Pair (frozen and FFPE) Fibrosis Fresh tissue in medium of choice Fibroma EDTA tube (lavender top) Other: ___________________ Paxgene tube Other: ________________________ 10. Quantity _______ Number of unique cases _______ Number of Specimens per case _______ For Biofluids: required minimum volume _______ For TMAs: # of cores/TMA 11. Inclusion/Exclusion Criteria 12. Data Description/Special Instructions/Other Comments If you have any questions about how to complete this form, or about our biospecimen respository, please email: [email protected] Office Use Only Reviewed by: _______________________ Approved by: _______________________ Database Entry: ____________________ Request Code Number Diagnostic Terms Acute Lymphoblastic Leukemia (ALL) Hodgkin Acute Myeloid Leukemia (AML) Non-Hodgkin Adrenocortical Carcinoma Burkitt’s Anal Cancer Male Breast Cancer Appendiceal Cancer Malignant Fibrous Histiocytoma Astrocytomas Medullary thyroid cancer Basal cell carcinoma Melanoma Bile Duct Cancer Anal Bladder Cancer Intraocular (Eye) Bone Cancer Merkel Cell Carcinoma Ewing Sarcoma Mesothelioma, Malignant Osteosarcoma Mouth Cancer/Oral cavity cancer Malignant Fibrous Histiocytoma Multiple Myeloma/Plasma Cell Neoplasm Brain Tumor Mycosis Fungoides Astrocytoma Myelodysplastic Syndromes Oligodendroglioma Myeloproliferative Neoplasms Ependymoma Myeloproliferative Disorders, Chronic Glioblastoma mutiforme Nasal Cavity and Sinus Cancer Breast Cancer Nasopharyngeal Cancer Male breast cancer Neuroblastoma Ductal carcinoma in situ (DCIS) Non-Hodgkin Lymphoma Burkitt Lymphoma Non-Small Cell Lung Cancer Carcinoid Tumor Oral Cancer Carcinoma of Unknown Primary Site (CUP; Occult Oropharyngeal Cancer Primary)Cardiac tumor myxoma Osteosarcoma Cervical Cancer Ovarian Cancer, epithelial Chronic Lymphocytic Leukemia (CLL) Pancreatic Cancer Chronic Myelogenous Leukemia (CML) Pancreatic Neuroendocrine Tumors (Islet Cell Tumors) Chronic Myeloproliferative Disorders Papillomatosis Colon Cancer Paraganglioma Cutaneous T-Cell Lymphoma Paranasal Sinus Cancer Ductal Carcinoma In Situ (DCIS) Parathyroid Cancer Endometrial cancer Penile Cancer Ewing Sarcoma Pharyngeal Cancer Eye tumor, Ocular cancer Pheochromocytoma Fibroma Pituitary Tumor Gallbladder Cancer Plasma Cell Neoplasm/Multiple Myeloma Gastric (Stomach) Cancer Pleuropulmonary Blastoma Gastrointestinal Stromal Tumors (GIST) Primary Central Nervous System (CNS) Lymphoma Prostate Cancer Germ Cell Tumor Rectal Cancer Ovarian Renal Cell (Kidney) Cancer Testicular Renal Pelvis / Ureter, Transitional Cell Cancer Hairy Cell Leukemia Retinoblastoma Head and Neck Squamous Cell Cancer Rhabdomyosarcoma Hepatocellular (Liver) Cancer Salivary Gland Cancer Histiocytosis, Langerhans Cell Childhood Hodgkin Lymphoma (Hodgkin’s disease) Sarcoma Islet Cell Tumors, Pancreatic Neuroendocrine Tumor Ewing Sarcoma Family of Tumors Kaposi Sarcoma Kaposi Kidney cancer/Renal cell carcinoma Osteosarcoma Wilm’s tumor Rhadomyosarcoma Langerhans Cell Histiocytosis Soft Tissue Laryngeal Cancer Uterine, Leiomyosarcoma Leiomyosarcoma Sézary Syndrome Leukemia Skin Cancer Acute Lymphoblastic (ALL) Melanoma Acute Myeloid (AML) Merkel Cell Carcinoma Chronic Lymphocytic (CLL) Nonmelanoma Chronic Myelogenous (CML) Basal cell Hairy Cell Squamous cell Lip cancer Throat Cancer Liver Cancer (Primary) Thymic Carcinoma Lobular Carcinoma In Situ (LCIS) Thymoma Lung Cancer Thyroid Cancer- excluding medullary Non-Small Cell, any/all Transitional Cell Cancer of the Renal Pelvis and Ureter Adenocarcinoma Trophoblastic Tumor Squamous cell carcinoma Unknown Primary, Carcinoma of Large cell carcinoma Ureter and Renal Pelvis, Transitional Cell Cancer Bronchoalveolar Urethral Cancer Small Cell Uterine Cancer, Endometrial Lymphoma Uterine Sarcoma AIDS-Related Vaginal Cancer Cutaneous T-Cell Vulvar Cancer .
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