OSTEOARTHRITIS INITIATIVE IMAGE

OSTEOARTHRITIS INITIATIVE
BIOSPECIMEN REQUEST FORM


   

1. Type and quantity of sample requested (refer to BRAC application for maximum allowable specimen) and at which visit specimens were collected:

    Visits Specimens were Collected
        Baseline 12-mo 18-mo 24-mo 30-mo 36-mo 48-mo 72-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 (include brief narrative). 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 (include references or a detailed description if not yet published):

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

6. Can previously thawed samples be used? In general, most samples will have undergone one thaw for sub-aliquoting.

   Yes        No  down arrow

7. Sample shipping address and contact:

 
 
 
 
 
 
   

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

9. Funding status:

 Funding secured
 Application for funding requires prior approval of this request

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 participant ID numbers (see instructions on OAI Online website for file type, file naming conventions, and transfer of 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 from subaliquoting the sample before shipment. In most cases, only the amount approved will be shipped. If a larger aliquot is shipped (unthawed specimens), I will limit and track the number of thaws and remove no more than the amount approved. All remaining specimen will be returned to the study repository at my cost.
   
  
 
 

Signature of Investigator
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Revised 9/03/14