Isolate or Specimen Request Application
Instructions:
1. Provide detailed answers. The more information we have, the better we can review your application.
2. Complete the entire application. Incomplete applications will be returned without review.
3. Include all requested attachments if available.
4. Your responses do not need to be limited to the space provided. If necessary, additional information may be requested.
Principal Investigator Information
Principal Investigator Information
Purpose of Study
Purpose of Study
Study Title
Study Title
Study Description (please include timeframe, study question, objectives, hypothesis)
Type of Material Requested
Type of Material Requested
 
What types of clinical specimens are you requesting?
What types of clinical specimens are you requesting?
 
How many stool samples are you requesting?
How many stool samples are you requesting?
How many blood samples are you requesting?
How many blood samples are you requesting?
How many nasopharyngeal specimens are you requesting?
How many nasopharyngeal specimens are you requesting?
How many sputum samples are you requesting?
How many sputum samples are you requesting?
How many of this sample type are you requesting?
How many of this sample type are you requesting?
What genus and species of bacteria are you requesting and how many individual isolates?
What viruses are you requesting and how many individual strains?
What kind of nucleic acid extracts are you requesting?
What kind of nucleic acid extracts are you requesting?
Describe the source of the DNA extract and how many extracts you are requesting.
Describe the source of the RNA extract and how many extracts you are requesting.
What quantity of this material are you requesting?
What quantity of this material are you requesting?
Will the results of the study be used for publication?
Will the results of the study be used for publication?
Please provide any additional comments that support your request.