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Project proposal In cooperation with the

Institute of Surgical Pathology

Institut für Klinische Pathologie 79002 Freiburg, Postfach 214 Direktor: Prof. Dr. M. Werner

Telefon: 0761 270-81190 oder 0761 270-81200

Telefax: 0761 270-81930

Name:

Clinic/Institute/Department:

Telephone: Email:

Objectives

Project duration: till (MM/YY)

DKTK SFB CCI BIOSS Others:

Coordinating investigator/Project leader

General Information

Research protocol

Project funding

Local or international Institutional Review Board (IRB) approval

The project is supported by:

The project is supported by the following Funding:

Title

Methods

reference number:

filed subsequently till:Pending,

Approved,

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Project proposal In cooperation with the

Institute of Surgical Pathology

Required Tissue

Biobank Request

Others:

Fresh frozen tissue Paraffin slides Number of required probes (Please attach the list):

Type of tumor/organ/tissue

Authorization procedure

The proposal should be approved by:

CCCF-Board Shared Ressources

CCI-Internal Board

Other

Scientific director of CCCF

Head of the Institute of Surgical Pathology

Cooperation Partner Head of the Institute of Surgical Pathology

Head of CCI

Manager of operating discipline Head of the Institute of Surgical Pathology

Other:

Pathology:

Cooperation Partner

Cooperation Agreement

Clinic:

Date Signature and seal

Date Signature and seal

Date Signature and seal

Institut für Klinische Pathologie

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Project proposal In cooperation with the

Institute of Surgical Pathology

Agreement

Protection of privacy

The provided biomaterial and data are only allowed to be used for the applied research objectives and must not hand over to a third party, not participating in this project. The remaining biomaterial should be returned to the Biobank after the research project is completed.

Written consent of the applicant

Date Signature and seal

I agree with the above listed agreements regarding the research proposal. Written consent of the Head of the Institute of Surgical Pathology

I agree with the above listed agreements regarding the research proposal.

Obligations under research

Biomaterial and data for research purposes are preserved and available solely after pseudonymization procedure. The Directive 95/46/EC of the European parliament and Council on the protection of individuals with regard to the processing of personal data and on the free movement of such data is strictly followed.

Date Signature and seal of the Applicant

Applicant Other:

Data bank access

We kindly ask you to provide your research results and record them in the data bank. The access is granted only for the applicant and his cooperation partner(s).

Pathology Resources

Laboratory space:

Working space:

Equipment:

Methods:

Co-Authorships

Head of the Institute of Surgical Pathology