Secondary Use of Biospecimens Ethics Compliance Form
Project Title
Principal Investigator
Institution/Affiliation
Email
Title of Original Study (if applicable)
Source of Biospecimens
Type of Biospecimens
Quantity/Volume Requested
Purpose of Secondary Use
Will biospecimens/data be identifiable?
Yes
No
Coded
Ethics/IRB Approval Number (if available)
Date of Approval
Was original informed consent obtained for future/secondary research use?
Yes
No
Unknown
Additional Information/Comments
Principal Investigator Signature
Date