OSTEOARTHRITIS INITIATIVE BIOSPECIMEN REQUEST FORM

	OSTEOARTHRITIS INITIATIVE BIOSPECIMEN REQUEST FORM

Reviewed January 7, 2013

BRAC Reference #:		Telephone number:
Name of investigator:		Fax number:
Institution:		E-mail address:
Country:

1. Type and quantity of sample requested:

		Visits Specimens were Collected
		Baseline	12-mo	18-mo	24-mo	30-mo	36-mo	48-mo
Citrated plasma	UL
EDTA plasma	UL
Serum	UL
Urine	UL
DNA	UL		*	*	*	*	*	*
RNA	UL	*					*

* Not extracted; investigator must provide funding for extraction.

2. Participant sample description (appropriate for manuscript methodology section); investigator is responsible for providing list of OAI participant ID #’s and a group indicator for each participant, e.g., 0=control, 1=case:

3. Assays planned (be specific; for DNA, attach list of genes and SNPs with RS # or other standardized unique identifier):

4. Methodology description sufficient for publication:

5. Specify for each analyte the quantity of biospecimen per assay, not including replicates or repeats; for example, Assay A: NTXI, 50 uL/assay x 3 for triplicates):

	ASSAY NAME	QUANTITY OF BIOSPECIMEN
Assay A:
Assay B:
Assay C:
Assay D:

6. Can previously thawed samples be used? In general, most samples will have undergone one thaw for sub-aliquating. Limited unthawed samples are available for highly labile analytes.

Yes No

Please justify:

7. Sample shipping address and contact:

FedEx account # to be charged for shipment:
Name of laboratory:
Contact person:
Telephone number:
Fax number:
E-mail address:
Shipping address:

	Street addres
	City
	State
	Country
	Postal or Zip Code

8. Contact information for person who will transfer assay result(s) to the OAI Coordinating Center at UCSF:

Name:
E-mail address:
Telephone number:

9. Funding status:

Funding secured
Letter of support required for application

10. Please review and initial each of the following statements:

I understand that only the assays specified above may be run. If I am interested in running additional assays, I must submit a new application to the OAI Biological Resource Allocation Committee.

I agree to electronically transmit the results from the assays specified above to the OAI Coordinating Center at the University of California, San Francisco, in exchange for decoding of sample barcode numbers to participantID numbers (see instructions on OAI Online website for file type, file naming conventions, and transferof data to UCSF secure gateway; data may NOT be transferred by email).

I will be responsible for all aliquoting, shipping, and reinventorying costs, including those resulting fromsubaliquoting the sample before shipment. In most cases, only the amount approved will be shipped. If a largeraliquot is shipped (unthawed specimens), I will limit and track the number of thaws and remove no more thanthe amount approved. All remaining specimen will be returned to the study repository at my cost.

Signature of Investigator

/
Month

/
Day

Year

For administration use only:

Date of approval:	/ Month	/ Day	Year
Date Request Form faxed to repository:	/ Month	/ Day	Year
Date assay results received by UCSF:	/ Month	/ Day	Year
Date decoded data returned to investigator:	/ Month	/ Day	Year