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
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 a Emory Principal Investigator?* 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 of 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 Academic Institution will review the budget proposal and MTA. If in agreeance, please e-mail the signed MTA to the GCRC Business Manager at michelle.rogers2@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 OTT department will review and negotiate the terms and conditions of the agreement as needed and btain 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 Other
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
If other, please list funding source* must provide value
Definition of de-identified Biospecimens and/or Data: does not contain PHI (must obtain IRB exemption status or expedited approval from the Emory IRB): If you are seeking to obtain de-identifiable specimen, you need to apply exemption status from IRB. (Include in your IRB application for reference.)
If you need help on your IRB application, please visit: http://www.irb.emory.edu/about/staff.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
COVID-19
Ebola Convalescent
Flu
Other
Please select COVID-19 sample type(s)* must provide value
NP Residuals
Bronchoalveolar Lavage (BAL)
Currently we only offer residual nasopharyngeal (NP) swab samples. We are currently working on the ability to provide other samples in the near future.
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.
Please select FLU sample type(s)* must provide value
NP Residuals
Please list other infectious disease type(s)* must provide value
Please list other sample type(s)* must provide value
IRB Approval Letter* must provide value
Protocol* must provide value
Name of individual submitting this request* must provide value
Submit
Save & Return Later
Working...