APGI BioResource Request Form Application for access to APGI BioSpecimens & data BioResource Request Form Step 1 of 8 - Instructions 12% Instructions to applicantsThis form has 5 sections (A-E). Section A, B and E are mandatory and must be completed in full. Section B and C may be completed depending on your project. Please read and carefully consider the following guidelines prior to submitting an application: 1. BioSpecimen and Data Access Policy This outlines the conditions of use of samples, restrictions that may apply to some cohorts and the requirements around investigator ethical approval. 2. APGI Bioresource Cost Recovery GuidelinesWe have a cost recovery process in place for all applications, and these guidelines provide researchers with a table of items associated with the provision of materials and information and indicative costs associated with these items. You will be provided with a quote for samples and/or data on receipt of your application to assist the process. Please note also it is a condition of use of the APGI BioResource that the APGI be acknowledged in publications arising from the use of BioSpecimens and/or data. This acknowledgement must appear in the Methods or Acknowledgements section as a minimum. Recommended wording is as follows: ‘ Biospecimens and/or clinical data were provided by the Australian Pancreatic Cancer Genome Initiative (APGI, www.pancreaticcancer.net.au’) which is supported by a PanKind Foundation Grant, www.pankind.org.au. At the end of the form you will be required to indicate you agree to be bound by the above policies and the Controlled Data Requirements. Once you’ve completed the mandatory sections of the form you will receive a notification of successful submission and copy for your records. Once you have finalized and submitted your form it is not able to be re-opened and edited. Please email us at research@pancreaticcancer.net.au if you have any questions. Section A - Applicant DetailsFor the purpose of this project.A.1. Name of Applicant*If the applicant is requesting ICGC BioSpecimens (including Tissue Microarrays), the applicant must be a Principal Investigator or Chief Scientific Officer. Mr.Mrs.MissMs.Dr.Prof.Rev. Title First Last A.2. Primary AffiliationPosition Title:* Group: Primary Afiliation:* Institution Website: A.3. Contact InformationInstitution:* Applicant's position Address Street Address Address Line 2 City State / Province / Region Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Telephone: Institutional Email Address:* A.4. Principal Investigator DetailsPlease only complete if different from above. The Principal Investigator will be classed as the authorised institutional representative to ensure adherence to policies.Name:* First Last Group: Primary Affiliation:* Institution Website: A.5. Names of Authorised Personnel or Students (within your institution)Please include all investigators, collaborators and research staff who will have access to APGI controlled data in order to work on the project. Please include an additional page i further names are to be provided.Authorised Personnel Name: Group: Primary affiliation: Institution website: Actions Edit Delete There are no personnel. Add person Maximum number of personnel reached. Section B - Project detailsThe project must be a cancer-related research project.B.1. Project InformationProject Title:*Project Website: Planned project duration*Please provide start and end dates. Please think realistically about the timeline of your project and the proposed outcomes. Please note that the above date will form the Maximum approval period and the Material Transfer Agreement (MTA) will be aligned to this date. At the end of the planned project duration your project approval will cease. B.2. Project descriptionPlease provide a clear description of the project and its specific aims in no more than 500 words.Scientific abstract*B.3. PublicationsList three (3) relevant publications in which you were an author or co-author.Publication 1 Title:Publication 1 Journal: Publication 1 DOI: Publication 2 Title:Publication 2 Journal: Publication 2 DOI: Publication 3 Title:Publication 3 Journal: Publication 3 DOI: B.4. Project Lay SummaryPlease provide a short, jargon-free description of the project for the general public in no more than 150 words. This summary may be published on our website.Project Lay SummaryB.5. MethodologyPlease provide a detailed analysis plan of your methods including a statistical plan if using data, and technical and scientific methodologies if using BioSpecimens.Methodology Section C - BioSpecimen Access?Biospecimen refers broadly to all tissue, blood and derived products. It also applies to cell lines and digital images. Access to BioSpecimens*Do you require access to APGI BioSpecimens?YesNo Section C - BioSpecimen AccessC.1. BioSpecimen Type & QuantityElaborate your requirements as thoroughly as possible so we can assess BioSpecimen type and availability that best suit your needs. Please refer to the BioSpecimen Availability Summary on our website to see an updated list of available BioSpecimens.Sample requirements Sample Type: Cohort Quantity Actions Edit Delete There are no Samples. Add Sample Maximum number of samples reached. C.2. Justification for number of cases requiredIf relevant, please provide a statistical power analysis.Statistical power analysisC.3. BioSpecimen CollectionAs outlined in the BioSpecimen & Data Policy, the APGI does not pay for shipping. Assistance with arranging couriers is available (where possible). We will contact you to confirm dates however it is preferable for shipments to depart on a Monday or Tuesday.How will the BioSpecimens be collected?*PickupCourierCourier Company: Account number: Reference: Contact Name: Telephone: Institution: Delivery Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Section D - Clinical data accessDo you require access to APGI clinical data?*NoYesD.1. Datapoints to be extractedPlease list the clinical data points to be extracted. Where relevant, please provide a brief description of what you require. Some data may not be available or is under restricted access. Please refer to the BioSpecimen & Data Access Policy for more information. Section E - EthicsThis section must be completed to be eligible for submission.E.1. Ethics summary*The APGI is ethically approved for the collection and curation of the BioSpecimens available for request. All individual projects must have their own ethics approval for the conduct of the project under consideration. The APGI is not responsible for the ethics approval/monitoring of individual research projects and bears no responsibility for the investigator's failure to comply with local and national ethical requirements. This project has been reviewed by an institutional review committee that has been formally designated to approve and/or monitor research involving humans with the aim of protecting the rights and welfare of the research participants. The approval letter/s is/are attached (an institutional number should also be provided if available). Ethics has been waived. A letter is attached, signed by the institutional review ethics committee. Neither of the above apply, please justify: Ethics justification*Supporting documentationPlease attach supporting documentation including evidence of ethical approval or waiver. Upload up to 3 files. (PDF, DOCX) Drop files here or Select files Accepted file types: pdf, doc, docx, Max. file size: 2 MB, Max. files: 3. E.2. APGI controlled data requirementsAccess to APGI clinical data is a procedure that entails legal and ethical obligations. We require that you and your institution have a modern, up to date, information technology (IT) policy in place that must minimally include the following items: Logging and auditing of access to data and to the computer network Password protection to the computer network Virus and Malware protection to computers on the computer network Auditable Data destruction procedure, when necessary Secure data backup procedure, when necessary Agree to procedures*You must agree to the following procedures in order to have access to APGI controlled data: I will keep all computer systems on which APGI controlled access data reside, or which provide access to such data, up to date with respect to software patches and antivirus file definitions (if applicable). I will protect APGI Controlled Access Data against disclosure to unauthorised individuals. I will monitor and control which individuals have access to APGI Controlled Access Data I will destroy all copies of APGI Controlled Access Data in accordance with the terms and conditions of this agreement. I will familiarise all individuals who have access to APGI Controlled Datasets with the restrictions of its use. I agree to swiftly provide a copy of both my institutional and project related IT policy documents upon request from an APGI representative. Agree to terms*I have read and agree to abide by the terms and conditions outlined in this agreement and the BioSpecimen & Data Access Policy YESApplicant name* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last Signature Review submissionPlease carefully review the data below before proceeding. You may navigate to previous pages and update any information before submitting.{all_fields}PhoneThis field is for validation purposes and should be left unchanged.
