Application For An Off Site Tissue Banking Va 10-0436
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7Application for an Off-Site Tissue Banking
Waiver at a Non-Profit or Academic Institution
INSTRUCTIONS
This form may be filled in and saved using Adobe Reader version 7.0 or higher. The full version of Adobe
Acrobat is not needed.
When you have completed the application, please e-mail it to the ACOS/R or designated person in your
Research Office. The Research Office should forward the application to Kristina Hill in Central Office.
Please answer all questions. If a question does not apply, please insert “N/A.” Additional information that would
help us review your application should be added on page 5 in section 9D.
Before using this application, make sure that the following apply:
The biological specimens will be collected and stored for future research purposes that are beyond the
scope of work described in the original protocol and informed consent or the biological specimens will be
collected under a protocol designed for banking of specimens.
Biospecimens will be banked outside of the VA at a non-profit or academic institution (e.g., university or
NIH-sponsored biorepository).
The study is sponsored by a non-profit institution or if the study is sponsored by a for-profit company,
biospecimens will not be sent to the company.
1. VA MEDICAL CENTER
A. Station no.
B. Name and location (city, state)
2. VA PRINCIPAL INVESTIGATOR
A. Last name, first name
B. Degree(s)
C. VA paid status
WOC
D. Telephone
E. E-mail
3. ACOS FOR RESEARCH AND DEVELOPMENT
A. Last name, first name
B. Degree(s)
C. Telephone
D. E-mail
4. PERSON COMPLETING THIS FORM
A. Last name, first name
B. Degree(s)
C. Telephone
D. E-mail
Page 1 of 7
VA FORM 10-0436
MARCH 2009
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