Do any of these apply to you?

- Will the results of the specimen analysis be published?

- Will the results of the specimen analysis be disclosed outside of your laboratory, such as in a presentation in a scientific lecture?

- Will you maintain records of the specimen analysis to be used in later studies?

- Are the samples being collected for any purpose other than validation of a laboratory test?

- Will these samples be used for any type of genetic sequencing?

* must provide value

Do any of these apply to you?

- Will the results of the specimen analysis be published?

- Will the results of the specimen analysis be disclosed outside of your laboratory, such as in a presentation in a scientific lecture?

- Will you maintain records of the specimen analysis to be used in later studies?

-Are the samples being collected for any purpose other than validation of a laboratory test?

- Will these samples be used for any type of genetic sequencing?

Yes

No

Not sure

Will the results of the specimen analysis be published?

* must provide value

Yes No

Will the results of the specimen analysis be disclosed outside of your laboratory, such as in a presentation in a scientific lecture?

* must provide value

Yes No

Will you maintain records of the specimen analysis to be used in later studies?

* must provide value

Yes No

Are the samples being collected for any purpose other than validation of a laboratory test?

* must provide value

Yes No

Will these samples be used for any type of genetic sequencing?

* must provide value

Yes No

If the answer to any question above is "yes" the study must be reported to Emory’s IRB located here . The IRB protocol is required before any specimens can be distributed.

If you do not have an approved IRB protocol and would like to see an example of IRB language requesting Biorepository samples, please see the attachment below.

Are you employed by Emory?

* must provide value

Yes No

Emory University Principal Investigator name

* must provide value

Emory University department

* must provide value

Anesthesiology Biochemistry Biomedical Engineering Biomedical Informatics Cell Biology Dermatology Emergency Medicine Family & Preventative Medicine Gynecology / Obstetrics Hematology / Medical Oncology Human Genetics Medicine Microbiology / Immunology Neurology Neurosurgery Ophthalmology Orthopedics Otolaryngology Pathology & Laboratory Medicine Pediatrics Pharmacology & Chemical Biology Physiology Psychiatry & Behavioral Sciences Radiation Oncology Radiology & Imaging Sciences Rehabilitation Medicine Surgery Urology

Emory University division

* must provide value

Cardiology Digestive Diseases Endocrinology General Medicine Geriatrics and Gerontology Hospital Medicine Infectious Diseases Pulmonary, Allery, Critical Care, and Sleep Medicine Renal Medicine Rheumatology

Emory University Principal Investigator e-mail

* must provide value

Emory University Principal Investigator phone number

* must provide value

Please provide speedtype for billing purposes

* must provide value

For Billing and Payment processing, the asscoiated speedtype is required for submission. The Georgia CTSA Clinical Research Biorepository Core Laboratory will not bill your account without your knowledge. During the billing period an invoice will be submitted to the Principle Investigator and Study Team for review and approval

RAS/Financial Analyst name

* must provide value

If contact is unknown please enter n/a

RAS/Financial Analyst e-mail

* must provide value

Please note: To facilitate the transfer of biological material between collaborators at different Institutions, a Material Transfer Agreement (MTA) is required and must be attached within this submission.After the Recipient Scientist review and approve the budget provided by the Georgia CTSA Clinical Research Centers Biorepository, the MTA procedures found below will be initiated. Emory University standard MTA agreement can be found here

MTA Procedures

Step 1: The Recipient Scientist and their Institution will review the budget proposal and MTA. If in agreeance, please e-mail the signed MTA to the GCRC Business Manager at sherrionda.grady@emoryhealthcare.org and gcrc@emory.edu

Step 2: The MTA will be logged for tracking purposes and routed to the appropriate contract office.

Step 3: Emory's OTT department will review and negotiate the terms and conditions of the agreement as needed and obtain all authorized signatures.

Final Step: Transfer of material occurs upon execution of agreement.

Non-Emory Principal Investigator name

* must provide value

Non-Emory Principal Investigator affiliation

* must provide value

CHOA Georgia Tech Morehouse UGA External Academia Industry

If other, please provide affiliation

* must provide value

Non-Emory Principal Investigator e-mail

* must provide value

Non-Emory Principal Investigator phone number

* must provide value

Please list billing details (contact, address, phone, etc.)

* must provide value

Is the preferred contact different from the Principal Investigator?

* must provide value

Yes No

Preferred contact name

* must provide value

Preferred contact e-mail

* must provide value

Preferred contact phone number

* must provide value

Study title

* must provide value

Study description

* must provide value

Please include study purpose, hypothesis and how you intend to use the Biorepository samples

Primary funding source

* must provide value

Investigator-initiated

Industry

NIH

Other federal agency

Foundation

Other

Investigator-initiated

Industry

NIH

Other federal agency

Foundation

Other

If other, please list funding source

* must provide value

Definition of de-identified Biospecimens and/or Data does not contain PHI and must obtain IRB exemption status or expedited approval from the Emory IRB. If you are seeking to obtain de-identifiable specimens, you need to apply for an exemption status from the IRB and include it in your IRB application for reference.

If you need help on your IRB application, please visit: https://www.irb.emory.edu/members/index.html

For additional information regarding office hours, please visit: http://www.irb.emory.edu/about/index.html

For more information regarding IRB guidance for exemption, please see: http://www.irb.emory.edu/index.html

Infectious disease sample(s)

* must provide value

Cervical/Vaginal

COVID-19

Ebola Convalescent

Flu

HPV

Other

Cervical/Vaginal

COVID-19

Ebola Convalescent

Flu

HPV

Other

Please select COVID-19 sample type(s)

* must provide value

NP Residuals

Bronchoalveolar Lavage (BAL)

Anterior Nasal

NP Residuals

Bronchoalveolar Lavage (BAL)

Anterior Nasal

How many NP Residual COVID-19 samples do you need?

Total Number Positive Samples Negative Samples

Number of requested samples NP Residuals COVID-19

How many of the samples are positive NP Residuals COVID?

How many of the samples are negative NP residuals COVID?

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NP Residuals COVID-19 total

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How many Bronchoalveolar Lavage (BAL) samples do you need?

Total Samples Positive Samples Negative Samples

Number of requested samples Bronchoalveolar Lavage (BAL)

How many of the samples are positive Bronchoalveolar Lavage (BAL)

How many of the samples are negative Bronchoalveolar Lavage (BAL)

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positive Bronchoalveolar Lavage (BAL) cost

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Negative Bronchoalveolar Lavage (BAL) cost

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Bronchoalveolar Lavage (BAL) total

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How many Anterior Nasal samples do you need?

Total Samples Positive Samples Negative Samples

Number of requested samples Anterior Nasal

How many of the samples are Anterior Nasal

How many of the samples are Anterior Nasal covid negative?

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positive Anterior Nasal Covid cost

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Negative Anterior Nasal Covid cost

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Anterior Nasal Covid total

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Please select EBOLA Convalescent sample type(s)

* must provide value

Plasma

Currently we only offer plasma samples. We are currently working on the ability to provide other samples in the near future.

How many Ebola Plasma samples do you need?

Total Number Positive Samples Negative Samples

Number of requested Ebola Plasma Samples

How many of the samples are positive Ebola Plasma Samples

How many of the samples are negative Ebola Plasma Samples

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positive Ebola Plasma Samples Cost

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Negative Ebola Plasma cost

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Negative Ebola Plasma total

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Please select FLU sample type(s)

* must provide value

NP Residuals

Anterior Nasal

NP Residuals

Anterior Nasal

How many Anterior Nasal samples do you need?

Total Number Positive Samples Negative Samples

Number of requested Andterior Nasal Samples

How many of the samples are positive Flu_anterior_nasal Samples

How many of the samples are negative flu_anterior_nasal Samples

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positive flu_anterior_nasal Samples Cost

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Negative flu_anterior_nasal cost

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Negative flu_anterior_nasal total

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How many NP Residual Flu samples do you need?

Total Number Positive Samples Negative Samples

Number of requested NP Residual Flu

How many of the samples are positive NP Residual Flu

How many of the samples are negative NP Residual Flu Samples

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Negative NP Residual Flu cost

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positive NP Residual Flu Samples Cost

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Negative NP Residual Flu total

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Please list other infectious disease type(s)

* must provide value

Please list other sample type(s)

* must provide value

Please select HPV sample type(s)

* must provide value

Cervical/ Vaginal

How to add new sample types 1, If you haven't already, go to 'data exports, reports, and stats' click the 'all data' reports button 'export data' click 'csv/microsoft excel (raw data), and press export data (this saves a copy of the datatbase in case anything goes wrong) Add a sample type in the infectious_disease_sample dropdown or its subsidiaries such as sample_type, or ebola_plasma_samples as needed 2, Then copy: bal_residual_numbers_4 requested_number_hpv_cervical (and all 4 other grey highlighted fields. Drag them to thier separate area (below the correct sample type) give the a unique color give them appropriate variable names make sure the branching and calculated values work See 3 lower on this page!!!!!

How many Cervical/Vaginal samples do you need?

Total Number Positive Samples Negative Samples

Number of requested HPV Cervical/Vaginal samples

How many of the samples are HPV Cervical/Vaginal

How many of the samples are HPV Cervical/Vaginal Samples

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Negative HPV Cervical/Vaginal cost

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positive HPV Residual Cervical/Vaginal Samples Cost

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HPV Residual Cervical/Vaginal total

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Protocol

* must provide value

Name of individual submitting this request

* must provide value

3, To add the positive and negative sample requests in the budget, Copy: proposed_budget_14 proposed_budget_15 Drag the coppied version below originals Change the name from 'HPV Cervical/vaginal' to your new sample type Make sure the branching works with the new sample type so it can show in the budget Correct the piping fields to reflec the new sample type go to 4 to complete!!

BIOREPOSITORY SERVICES

Services Quantity Unit Cost Total

Positive NP Residuals COVID-19

______

$______ .00

$______ .00

Negative NP Residuals COVID-19

______

$______ .00

$______ .00

Positive Bronchoalveolar Lavage (BAL)

______

$______ .00

$______ .00

Negative Bronchoalveolar Lavage (BAL)

______

$______ .00

$______ .00

Positive Anterior Nasal COVID-19

______

$______ .00

$______ .00

Negative Anterior Nasal COVID-19

______

$______ .00

$______ .00

Positive Ebola Plasma

______

$______ .00

$______ .00

Negative Ebola Plasma

______

$______ .00

$______ .00

Positive NP Residual Flu

______

$______ .00

$______ .00

Negative NP Residual Flu

______

$______ .00

$______ .00

Positive Anterior Nasal Flu

______

$______ .00

$______ .00

Negative Anterior Nasal Flu

______

$______ .00

$______ .00

Positive HPV Cervical/Vaginal

______

$______ .00

$______ .00

Negative HPV Cervical/Vaginal

______

$______ .00

$______ .00

*Costs are inclusive of Emory F&A Rate @ 56.5%

* Your bill was calculated based on your stated primary funding source: ______

BIOREPOSITORY SERVICES

Description of Services Quantity Unit Cost Total Positive ______ $______ .00 $______ .00 Negative ______ $______ .00 $______ .00 Total Budget $______ .00

*Costs are inclusive of Emory F&A Rate @ 56.5%

* You bill was calculated based upon your stated primary funding source: ______

*IMPORTANT: You have chosen 'Other',

- Disease Types: ______

- Sample Types: ______

As we do not have pre-defined prices for these items, this cost will be added to your quote later.

*IMPORTANT: You have chosen 'Ebola Plasma Samples',

As we do not have pre-defined prices for these items, this cost will be added to your quote later.

4, You need to update the nested sum tables to add the new sample to the budget. Update: total_budget requested_number positive_samples negative_samples Calculated Fee
example of nested if table:
@CALCTEXT(if([attending] = '1', 'EBURD@emory.edu', if([attending] = '2', 'eric.charles.fitts@emory.edu', if([attending] = '3', 'cehill@emory.edu', if([attending] = '4', 'colleen.kraft@emory.edu','')))))

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total budget
sum(if(______ != "", ______ , ""), if(______ !="", ______ , ""), if(______ != "", ______ , ""), if(______ !="", ______ , ""), if(______ !="", ______ , ""), if(______ !="", ______ , "") , if(______ !="", ______ , "") , if(______ !="", ______ , "") , if(______ !="", ______ , "") , if(______ !="", ______ , ""))

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Number of requested samples How many samples are positive? How many samples are negative?

Number of requested samples (this will be a calculate total to keep the backend data consistent with the old system)

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How many of the samples are positive? (this will be a calculate total to keep the backend data consistent with the old system)

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How many of the samples are negative? (this will be a calculate total to keep the backend data consistent with the old system)
______ + ______ + ______ + ______ + ______ + ______

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