Data, Isolate, or Specimen Request Application
Instructions:
1. Provide detailed answers. The more information we have, the better we can review your application.
2. Complete the entire application. Incomplete applications will be returned without review.
3. Include all requested attachments if available.
4. Your responses do not need to be limited to the space provided. If necessary, additional information may be requested.
Principal Investigator Information
Principal Investigator Information
Name:
Organizational Affiliation:
Street Address:
City, State and Zip:
Phone:
Fax:
Email Address:
Purpose of Study
Purpose of Study
Verification of an Existing Method
Validation of a New Method
Data Request
Study Title
Study Title
Study Title
Study Description (please include timeframe, study question, objectives, hypothesis)
Study Description (please include timeframe, study question, objectives, hypothesis)
Type of Material Requested
Type of Material Requested
Clinical Specimen (e.g., blood, stool)
Bacterial Isolate
Viral Isolate
Nucleic Acid Extract
Data
Other
Other
What types of clinical specimens are you requesting?
What types of clinical specimens are you requesting?
Stool
Blood
Nasopharyngeal
Sputum
Other
Other
How many stool samples are you requesting?
How many stool samples are you requesting?
How many blood samples are you requesting?
How many blood samples are you requesting?
How many nasopharyngeal specimens are you requesting?
How many nasopharyngeal specimens are you requesting?
How many sputum samples are you requesting?
How many sputum samples are you requesting?
How many of this sample type are you requesting?
How many of this sample type are you requesting?
What genus and species of bacteria are you requesting and how many individual isolates?
What genus and species of bacteria are you requesting and how many individual isolates?
What viruses are you requesting and how many individual strains?
What viruses are you requesting and how many individual strains?
What kind of nucleic acid extracts are you requesting?
What kind of nucleic acid extracts are you requesting?
DNA
RNA
Describe the source of the DNA extract and how many extracts you are requesting.
Describe the source of the DNA extract and how many extracts you are requesting.
Describe the source of the RNA extract and how many extracts you are requesting.
Describe the source of the RNA extract and how many extracts you are requesting.
What quantity of this material are you requesting?
What quantity of this material are you requesting?
Will the results of the study be used for publication?
Will the results of the study be used for publication?
Yes
No
Unknown
Describe the type of data you are requesting.
Describe the type of data you are requesting.
Please provide any additional comments that support your request.
Please provide any additional comments that support your request.
By submitting this application, the receiving institution agrees to the following:
-To provide Idaho Bureau of Laboratories with review rights - prior to publication - of any document that reports Idaho-specific data.
-To provide Idaho Bureau of Laboratories a final copy of any publications, results, reports, etc., derived from the use of the materials.
-To indemnify and hold harmless Idaho Bureau of Laboratories and Idaho Department of Health and Welfare from damages resulting from the use and/or misuse of the materials.
- That the authorization to release this material does not imply endorsement of this study or its findings by either Idaho Bureau of Laboratories or Idaho Department of Health and Welfare.