Washington University Center for Kidney Disease Research

	   

INSTRUCTIONS: For the Washington University Kidney Translational Research Core (KTRC)

Human Specimen, Data or KTRC Service Request Form 

Use of existing, de-identified human specimens or data obtained from the Washington University

KTRC or to use KTRC services requires Washington University Medical School Human Research 

Protection Office (WUMC HRPO) approval or an Institutional Review Board (IRB) equivalent.

In most cases, because of minimal patient risk, the protocol review may be expedited. 

Because the samples and services offered are limited each written request will be reviewed 

by the Washington University KTRC Oversight Committee with the following:  

1.	HPRO or Institutional Review Board equivalent approval letter.  
2.	Signed Code Access and Specimen Utilization Agreement (below)
3.	Washington University KTRC Specimen and Data Request Form (below). 

Submit to: The Washington University Kidney Translational Research Core (KTRC)
Attention: For biospecimens of patients for kidney transplant research 
Daniel C. Brennan, MD (director) 
Campus Box 8126
Phone: 314-362-8351
Fax: 314-362-2713
E-mail: brennan@wudosis.wustl.edu

For biospecimens of patients for non kidney transplant research
Sanjay Jain, MD, PhD (co-director)
Campus Box  8126
Phone: 314-454-8728
Fax: 314-454-7735
Email: sjain22@wustl.edu

REQUEST FORM: The Washington University (WU) Kidney Translational Research Core (KTRC) 

Code Access and Specimen and Data Use Agreement: 

In accepting specimens or data requested on this form, the investigator and 

laboratory principal investigator both agree:

1.	To use specimens and data for research purposes only in compliance with 

	the cited WUMC HPRO or institutional equivalent approved protocol.
 
2.	To use appropriate safeguards to prevent Use of Disclosure of Data 

	other than as specified in the approved protocol.

3.	To not actively seek the individual patient identity of “de-identified” 

	(coded) specimens unless specifically approved in the study protocol.

4.	To certify that all individuals working with unprocessed tissue specimens 

	and body fluids have received and have documented appropriate training 

	in the handling of potentially infectious human specimens through the Division 

	of Environmental and Health Safety at Washington University 

	School of Medicine or institutional equivalent.

5.	To acknowledge that the specimens or data were obtained from the 

	Washington University KTRC and the Laboratory of Translational Pathology (LTP).

6.	To acknowledge the NIH grant P30 DK079333.

7.	That results from your studies will be included in the WU KTRC Database 

8.	To prohibit distribution or propagation of specimens or data to 

	other researchers who are not identified in the approved protocol.

9.	To notify the KTRC of any change in project funding status.

10.	To agree to share the biospecimens with other KTRC investigators.

11.	To assume financial responsibility for all sample processing charges.


Signed:                                                                                                        
Investigator Name:  _____________________

                                                                                      
Investigator Title: _____________________

                                                                                          
Institution: ______________________________________________________________


Date:                          

                                                                                    
The Washington University Kidney Translational Research Core (KTRC)
Human Specimen, Data and Services’ Request Form



Date: __________________________


Requested by:  ___________________________________________________________


Principal Investigator:  _________________________________________________


Department/Institution:  _________________________________________________


Telephone: _________________________      E-mail:  _______________________


Protocol Title and WUMS HRPO or institutional equivalent number:  


Funding sources for the proposed study:





Attach a brief (~300 word or less) description of the proposed study, including:
•	Specimens (state blood DNA, RNA, serum, plasma, urine and amount) or data or Service
	(enrolling patients, designing studies, IRB help, biobanking specimens) requested
•	Scientific rationale (include kidney disease or patient population being studied)
•	Type of assay to be performed with the specimens or data
•	Justification for the number and type of specimens or data
•	Justification for the type of associated pathology or clinical data needed
•	Relevance to the study of kidney disease
•	Planned use of study results (publication, grant application, abstract presentation, etc.)
•	Whether additional specimens or data may be requested for this study in the future