RTB Sample Access Application Form

Research Tissue Bank

Sample access application form
Application details

This application is for researchers who wish to gain access to samples obtained through BioGrad Limited without applying for separate NHS REC approval. Projects submitted must fall into the scope of one of Biograd's ethically approved research programs, be feasible and of scientific merit. If you have already gained NHS REC approval and are looking to obtain samples through our Biobank please exit this form and contact our Commercial Operations team on +44 151 245 2469.
Are you an employee of BioGrad Limited?*

YesNo
Which of BioGrad's ethically approved research programs does your project align with?*

Women's healthCell therapies and related conditions
A1. Project title *
(max. 200 characters)
A2. Project synopsis *
Brief synopsis of the research detailing the aims of the project and intended outputs relating to the field of cell therapy research with specific focus on impact and public interest requirements (max. 200 words)
A3. Project duration*
A4. Please provide the scientific rationale of the proposed project and the potential value and prospective benefits to patients directly and/or the research community at large*
(max. 300 words)
A6. Do you have specific donor requirements such as samples from a particular patient group?*

YESNO
Please list your donor requirements below
A9. Does your project require us to re-contact donors (e.g. for additional samples or data)?*

YESNOI am not sure
Please provide a scientific justification for the additional sample or data requirement.*
A8. Do you require access to biological samples?*

YESNO
A7. Do you require a specific data set to be provided for your research?*

YESNO
Selection of samples and data

The purpose of this section is to clarify precisely which type of samples and data are required for your application and what is their intended use? We can provide fresh, frozen or processed samples. Please note that sample types accessible are limited to those listed below. If you wish to utilise BioGrad's clinical services to gain access to other sample types please exit this form and contact our clinical team.

Maximum freeze thaw cycles
Please clarify the type of processed sample you wish to obtain
We routinely process samples and store components such as Plasma, Serum and Cells for research-use. We can also provide DNA/RNA extraction services. Please provide details of your processing requirements (e.g. concentration of DNA).
Please list the data you require to obtain with your sample*
We routinely collect donor data such as age, sex and ethnicity as well as medical and life-style information.
Please describe what procedures/methods you will use on sample and/or data obtained?*
(max. 300 words)
Quality assurance
As provider of donated sample we have a duty to ensure that the samples and data we provide will be kept safe and in line with regulatory guidelines. Please provide below a summary of your processes for sample storage and data protection. *
Applicant
Name*

First NameLast Name
Job Title
Email*
example@example.com
Institution*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Will the named applicant act as the principle investigator for the project?*

YESNO
Name of principle investigator*

First NameLast Name
Email*
example@example.com
Please give details of the principle investigator's experience relevant to the project*
File Upload*

Please upload the CV of the principle investigator
Cancelof
Finance and Facilities
Please describe your facility setup in relation to the work you aim to carry out on the provided samples. *
If you are intending to send samples obtained through BioGrad to an external lab to conduct assays as part of your project please provide details of the proposed lab
Please describe how your work is funded and the status of any funding applications if relevant. *
File Upload*

Please upload any evidence of financial support for your project that you can provide (e.g. grant approval letters, financial statements, financial support letter, collaborative agreements). Failure to upload evidence may result in delayed processing of your application.
Cancelof
Previous ethics applications
Were you previously declined ethics approval for this project (e.g. by NHS REC or another Biobank)?*

YesNo
Please share with us the reasons for rejection and outline how you have addressed the concerns. *
File Upload

Please upload documentation relating to the reasons for previous ethics rejections
Cancelof
Regulatory evidence
Does your project involve use of animals for research purposes?*

YESNO
Does your project involve GMO work?*

YESNO
Does your project involve work that is regulated by any other regulation with exception of the HTA Act?*

YESNO
Please elaborate
Please describe how you are meeting regulatory requirements related to your project?*
File Upload

Please upload evidence of any regulatory licences/approvals required for your project. This could include Home office licences, approval letters or a statement of your organisation). Failure to do so will result in delay of processing your application.
Cancelof
Should be Empty:

	Number of donor samples	Volume per sample	State of sample	Specific requirements (e.g. type of tissue)
Amniotic fluid by Amniotomy
Blood Collection by Leukapheresis (Leukopak)
Bone Marrow
Breast Milk
Cerebral Spinal Fluid
Lochia
Menstrual Blood
Molar Teeth
Nasal Swab
Peripheral Blood
Placenta
Post-Menopausal Bleeding
Rectal Swab
Saliva
Stoma Swab
Surplus Tissue following a Biopsy
Surplus Tissue following Surgery
Throat Swab
Umbilical Cord Blood
Umbilical Cord Tissue
Urine
Vaginal Swab
Wisdom Teeth

Research Tissue Bank

Application details

Selection of samples and data

Quality assurance

Applicant

Finance and Facilities

Previous ethics applications

Regulatory evidence