Application For An Off Site Tissue Banking Va 10-0436 Page 2

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5. TISSUE BANK(S)
If biospecimens are going to be stored at more than one tissue bank, please give the name, location, and
URL for each.
A1. Name of tissue bank
A2. Name of 2nd tissue bank, if applicable
B1. Location of tissue bank (city, state)
B2. Location of 2nd tissue bank, if applicable
C1. URL of tissue bank web site
C2. URL of 2nd tissue bank, if applicable
6. INFORMATION ABOUT THE STUDY
B. No. of subjects you plan to enroll at
A. Title of the study
this site:
C. Study sponsor
D. Grant or award no.
E. Start date
F. End date
G1. Are other VA Medical Centers participating in this study?
YES
NO
NOT SURE
G2. If Yes, please name the other Centers, if known. Note: Only one application should be submitted for all
participating VA Medical Centers.
H. Is IRB and R&D Committee approval contingent upon this waiver?
YES
NO
7. INFORMATION ABOUT THE BIOSPECIMENS
A. Types(s) of biospecimens collected and banked ( e.g., blood, lung
B. How long will the biospecimens be
tissue, buccal swab, DNA )
banked?
VA FORM 10-0436
Page 2 of 7
MARCH 2009

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