1. No category

ePhorte case number:
Filled in by The Prostate Biobank
Application to The Prostate Biobank (no. 119 Biobank Registry at The Norwegian
Institute of Public Health)
Send the signed form to the board of The Prostate Biobank v/Prof. Aud Svindland ([email protected])
1
Project title
2
Project leader (group leader or senior scientist)
Name:
Institution:
Clinic/Institute:
Phone:
E-mail:
3
Applicant (the acting researcher)
Name:
Klinikk
Institution:
Clinic/Institute:
Phone:
E-mail:
4
Collaborators (internal/external)
Name
Divition
Clinic/Institute
5
Goal (Primary-
6
Summary of project description (background, methods, results if relevant)
Institution
and subgoals)
7 Applies for excess to the following biological specimens or derived products derived. Fill inn number
of individuals and amount needed.
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Application to The Prostate Biobank (119)
Protein
RNA DNA
Set cross
Tissue
Number of
individuals
Amount (Specify µg or µl)
Macro-disseceted normal
Macro-dissected tumor
LMD normal epithelial
LMD tumor epitelhelial
LMD stroma
TMA
Serum
Plasma
DNA-from blood
Others (specify)
8
The following markers will be analyzed (genes/mRNA/proteins/lipids/glycoproteins/other)
9
Financial plan
10 Publication plan
11 Project periode
Start of project (date):
End of project (end):
12 Type of project (questions 10 – 17 have to be answered with YES or NO )
Researcher initiated
project:
Industry initiated
project:
Multi-centre project
headed by AUS:
Multi-centre project
headed by external
institution:
13 The project includes use of personal data such as health information that indirectly
can be linked to one specific person?
If YES – an application has to be sent and approved by Regional Committees for Medical and Health Research Ethics.
14a The project includes genetic studies that might affect the diagnosis or treatment of
the person involved?
If YES - the project is affected by the law of biotechnology and question 12b has to be answered.
b The project includes genetic studies that can predict disease or that the person
involved is carrier of a genetic disease?
If YES, genetic guidance has to be given (according to the law of biotechnology).
15 Is the project approved by Regional Committees for Medical and Health Research
Ethics?
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Application to The Prostate Biobank (119)
16 Persons connected to The Prostate Biobank will be co-authors on the resulting
publication(s) as long as they fulfill the guidance given by ”International
Committee of Medical Journal Editors”?
17 In the pulication(s) it should be written that the biological specimens comes from
The Prostate Biobank (10974) at Oslo University Hospital, Aker.
18 Information about the progress has to be given once a year.
19 The results obtained have be presented for Department of Anatomy and Pathology
and Oslo Urological University Clinic.
20 Expenses related to sampling and processing of the biological have to be covered by
the project leader.
Applicant
Date of approval:
Date:
Signature by board of The Prostate Biobank
Signature by applicant
The Prostate Biobank consider:
• Is the project of medical interest?
• Do we have relevant biological material available?
• Is the project of academic interst?
• Is the financial plan satisfactory?
• Has the research environment competence in the
methodology to be used?
Unused materiale has to be returned to The Prostate Biobank
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Leder
Application to The Prostate Biobank (119)
Access to CRESALYS
Rights (cross)
Name
User name
Reading only
Reading and writing
Personal data
Applicant
__________________________________________________________________________________________________________________________________
Godkjent av:
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