Part 1 of 6

A. Trial title and administrative information

Title of the TR study *

Name of Study Chair *

Institution of Study Chair *

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Institution where the TR study will be conducted *

What clinical trial from the GI Cancer Trials portfolio will the TR study will be attached to? *

Search for a trial and select one. If the trial you are looking for is not listed, it is not currently available for sample requests.

Available for sample accessThis field is hidden on the formYesNo

Samples collected from this trial are not available for access.

For more information, please contact info@gicancer.org.au.

Samples collected from this trial are available for access.

Biospecimens that can be considered for sample access are listed below. Please note the following for when you are asked to list your requested biospecimens.

DISEASE TYPE/S

 

 

 

TISSUE

Archival or FFPE tissueYesNo

Fresh tissueYesNo

RESEARCH BLOODS

PlasmaYesNo

SerumYesNo

Buffy coatYesNo

Whole bloodYesNo

OTHER

Other biospecimen available

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Part 2 of 6

B. Science (1 of 3)

1. Overview of TR study

Lay summary of overview *

Background *

Hypothesis *

Aim/s *

Methods *

Statistical analysis *

Part 3 of 6

B. Science (2 of 3)

2. Scientific and ethics committee approvals

Has the TR study been previously reviewed and approved by the relevant Trial Management Committee? *

YesNoUnsure

Date of approval

Has the TR study been included in the clinical trial protocol? *

YesNoUnsure

Does the master Participant Information Sheet and Consent Form permit the use of biospecimens for this research purpose? *

YesNoUnsure

Is there a current HREC approval for the TR study? *

YesNoUnsure

Part 4 of 6

B. Science (3 of 3)

3. Biospecimens requested

Tissue requested

Fresh frozenFFPE tissue block + H&E slideFFPE tissue core + H&E slideFFPE tissue sections + H&E slideFFPE normal tissue

Bloods requested

Whole bloodSerumPlasma (single/double spun)Buffy coat

Other biospecimens or derivatives requested

YesNo

 Please specify the biospecimen or derivative you are requesting.

Part 5 of 6

C. Funding

Please tick all that apply.

The TR study has funding that is external to the clinical trial budget.

Please indicate the source of funding. *

Please Indicate the amount externally funded. *

The TR study has allocated funding from the main clinical trial.

Please indicate the allocated amount. *

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Part 6 of 6

Completed by

Full name *

Position

Institution *

Email *

Contact phone number *If you are based outside Australia, please include country code. If applicable, please include area code.

Date submitted *

I consent to my data being collected and stored, as per the Privacy Policy terms at gicancer.org.au/privacy. *

I agree to adhere to the GI Cancer Trials Publications Policy. *

 

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