ࡱ> OQN  bjbj Fgg>     4448l4q$ 7# "  +TTTv  TTTTn[RTA0qT##TT# hthJTd<r^q# X :  Biorepository Sample Request Form Name: Institution: Contact Information (email; tel #): Date of Request: Sample Type Requested (ie. sputum, BAL, blood): Sample/aliquot Volume requested: Sample quantity requested: Subject Type requested (i.e. healthy/asthmatic/copd, etc): Exposure Study requested (please indicate if you require baseline/pre/post exposure samples): Detailed Description of Intended Use of the Samples: Do you intend to return any unused samples? Yes/No Do you agree to be the sole user of the requested samples? Yes/No If No, please provide a detailed explanation as to where besides your facility/lab the samples will be used What is your desired timeline for receiving the requested samples? Please list any previous occasions (date/sample type) where you have requested samples from the CEMALB Biorepository Will you require any demographic data/information regarding the requested samples? Yes/No if yes, please indicate the data/information you require Requester Signature: _______________________________ Date: ___________________      Center for Environmental Medicine, Asthma and Lung Biology 104 Mason Farm Road, Campus Box 7310, Chapel Hill, NC 27599-7310 "#$*+,89:]^_opq   z { | Q R S ! " # < = > ? @ A B C D E F G H I J K L M N h_]Rjh_]RUmHnHuhYkjhYkU hh5CJ$h4. h4.5\h"_CJaJO#$+,9:^_pq  { | gd4. p^p`gd4. 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