Sample Request Survey
About the request
Sample Type(s) of Interest
Disease Type(s) of Interest
Any Additional Requesting Criteria? (e.g. age above 60; smoking history etc.)
Sample Utilization Purpose (e.g. for pilot study or clinical research)
Description of the Project (e.g. abstract) (if applicable)
Funding Source (if applicable)
Did you obtain ethics approval from local ethics committee for your project?
Did you obtain ethics approval from local ethics committee for your project?
Yes
No
What is the name of the Institutional Review Board (IRB) or the Independent Ethics Committee (IEC)
Are you planning to obtain an ethics approval from local committee?
Are you planning to obtain an ethics approval from local committee?
Yes
No
Contact Information
Title
*
Title
Professor
Dr.
Mr.
Mrs.
Ms.
Name
Name
*
First
Last
Organization
*
Department (if applicable)
Position
*
Organization Origin (e.g. Hong Kong)
*
Are you the Principal Investigator (PI) of the project?
*
Are you the Principal Investigator (PI) of the project?
Yes
No
Name of PI
Name of PI
*
First
Last
Address
*
Tel
Fax
Email
*
Additional Comment(s) (if applicable)
Disclaimer
The personal data collected will be used by CU-Med Biobank and authorised personnel for processing the captioned purposes in accordance with relevant provisions of the Personal Data (Privacy) Ordinance.