Institutional Biorepository COVID-19 Biobank Sample/Data Request

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Principal Investigator

First Name

Middle Name

Last Name

Degrees

Position Title

Institution

Department, Service, Laboratory or Equivalent

Street Address

City

State

ZIP

Email Address

Phone Number

Fax Number

Is there a collaborating investigator on this project?

YesNo

Collaborating Investigator

First Name

Middle Name

Last Name

Degrees

Position Title

Institution

Department, Service, Laboratory or Equivalent

Street Address

City

State

ZIP

Email Address

Phone Number

Fax Number

Project Information

Title of Project

Performance Site

Project Contact Name

Project Contact Email

Project Contact Phone

Project Funding Source

AU/Cost Center

Project Goals and Objectives

Provide a concise, scientific summary of the project goals and objectives. Limit is 500 words (approximately 1 page single-spaced).

Are you requesting samples?

YesNo

Sample Number

Sample Type

DNABiospecimen

Biospecimen Type

Amount of Each Sample

Are you requesting data?

YesNo

Data Type

Identifying DataNon-Identifying Data

IRB Status

ApprovedPending

IRB Approval Date

Upload your IRB approval letter (PDF or .doc format)

Sample Justification

Justify the amount and number of samples requested, including power calculations if appropriate.

Analytical Procedures

List the analytical procedures to be used.

Lay Summary

Summarize the proposed research using non-technical language. Limit is 250 words.

How is this study funded? (Check all that apply.)

Extramural FederalExtramural Non-FederalIntramuralNone

Type of Extramural Federal Funding

HHSNIHNIMHOther

Specify Type of Extramural Federal Funding

Type of Extramural Non-Federal Funding

Industry, PI-InitiatedIndustry, Sponsor-InitiatedStateFoundationPrivateOther

Specify Type of Extramural Non-Federal Funding

Type of Intramural Funding

Penn State Campus-WideDepartmentalOther

Specify Type of Intramural Funding

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