Emory University
Children's Clinical and Translational Discovery Core
http://www.pedsresearch.org/research/cores/biorepository/overview/
M-D-Y
H:M
Email Address
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Submit a Sample(s) for Processing
Submit a Sample(s) for Storage
Submit a Sample(s) for Shipping
Request a Sample(s)
Request Supplies or Kits
Submit a Sample(s) for Processing
Submit a Sample(s) for Storage
Submit a Sample(s) for Shipping
Request a Sample(s)
Request Supplies or Kits
Please allow up to 3 business days for sample retrieval. Depending on the number of samples requested this time frame may be shorter or longer. The Biorepository will make every effort to retrieve your samples in the shortest time possible.
The CTDC staff may have additional questions concerning your request. We will use the email address provided to correspond with you if any questions arise while samples are being retrieved.
You will receive an email notification once all requested samples have been retrieved. All requested samples will be placed in a storage box and held at the appropriate temperature.
Are you requesting this sample from:
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Clinical Trial
General Biorepository
RADx/RADxtra
RADx-VTF
Clinical Trial
General Biorepository
RADx/RADxtra
RADx-VTF
Please use the form below to submit a sample(s) that will be processed and/or stored.
Please complete/answer all items on the sample processing requisition form. The data that you provide is used for sample identification, processing, and billing. It is important that all information that you provide matches the information that is written/entered in your source documents.
Please include, on the sample or sample bag, the Study Name and Study ID. This information will help avoid confusion that may arise when multiple samples have been submitted.
The CTDC staff may have additional questions concerning your request. We will use the email address provided to correspond with you if any questions arise while samples are being retrieved.
Please submit one REDCap record for each visit for which you are submitting samples.
Please use the form below to submit a sample(s) that has been processed at an external location and is being sent to the CTDC Lab for storage only.
Please complete/answer all items on the sample processing requisition form. The data that you provide is used for sample identification, processing, and billing. It is important that all information that you provide matches the information that is written/entered in your source documents.
Please include, on the sample or CryoVial, the Study Name, Subject Study ID, Visit Name, Date, and Sample Type. This information will help avoid confusion that may arise when multiple samples have been submitted.
The CTDC staff may have additional questions concerning your request. We will use the email address provided to correspond with you if any questions arise while samples are being retrieved.
Please submit one REDCap record for each visit for which you are submitting samples.
Please allow up to 24 hours for supply and/or study kit retrieval.
The CTDC staff may have additional questions concerning your request. We will use the email address provided to correspond with you if any questions arise while supplies and/or kits are being retrieved.
You will receive an email notification once all requested supplies and/or kits have been retrieved. Following receipt of this email you may pick-up your supplies and/or kits in the CTDC Lab.
For shipped kits, a tracking number will be provided in the completion form.
Study Name
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ADX-629-MCD-001 (Aldeyra) Aflac LL1401 Aflac ST1501 Aflac ST1502 Aflac ST1602 Aflac ST1603 Aflac ST17B1 Aflac ST1901 Aflac ST1903 Allosure ANBL1821 ANBL19P1 ANBL2131 APL2-201 APL2‑C3G-310 APL2-C3G-314 APOLLO ASPIRE Bausch Health (Protocol RBSC2161) BI 1434-0004 BMS IM101-566 CCPS CKiD Commute-A CONNECT COVID-19 - Healthcare Workers CureGN Database 3 EAGLE ECU-aHUS-312 ECU-aHUS-402 (Evidence) edTBI EoE FIT4KID GEM-IIT-601 GIN Biorepository Glomsphere HEPAFat HLHS INSHORE KiD-B MceHyb MiLK MIRCERA MOTIVATE MRX2834-001 MRX2834-1003 NAFLD Prevention NANT2017-01 Neptune NIMS NuSci Nutrinia GIFT-02 OBAD OPN HIE Otsuka 204 Otsuka 276 Otsuka 294 PAIH PINS PKTx (IMP) PLUMM Posterity Prokidney REGEN-004 R3R RADx-ELIAD Reata 402-C-1603 SHP626-201 Target-Nash TIC-TOK UTOPIA Velphoro (Vifor) VOCAL VX19-147-101 VX19-NEN-801 VX21-147-301 Zemplar
Study Name
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Aflac LL1401 Aflac ST1501 Aflac ST1502 Aflac ST1602 Aflac ST1603 Aflac ST17B1 Aflac ST1903 APL2-201 APOLLO ASPIRE BMS IM101-566 CCPS CONNECT COVID-19 - Healthcare Workers CureGN CVD EAGLE edTBI EoE ECU-aHUS-402 (Evidence) GEM-IIT-601 HEPAFat KiD-B MceHyb MiLK MIRCERA MOTIVATE MRX2834-001 NAFLD Prevention Neptune NIMS NuSci Nutrinia GIFT-02 OBAD Otsuka 276 Otsuka 294 PAIH PKTx (IMP) SHP626-201 Reata 402-C-1603 Target-Nash TIC-TOK UTOPIA Velphoro (Vifor) VX19-147-101 VX19-NEN-801 Zemplar
Study Name
* must provide value
Aflac LL1401 Aflac ST1501 Aflac ST1502 Aflac ST1602 Aflac ST1603 Aflac ST17B1 Aflac ST1901 Aflac ST1903 Allosure ANBL1821 ANBL19P1 APL2-201 APL2‑C3G-310 APL2-C3G-314 APOLLO ASPIRE Bausch Health (Protocol RBSC2161) BI 1434-0004 BMS IM101-566 CCPS CKiD CONNECT COVID-19 - Healthcare Workers CureGN Database 3 EAGLE ECU-aHUS-312 ECU-aHUS-402 (Evidence) edTBI EoE FIT4KID GEM-IIT-601 Glomsphere HEPAFat HLHS KiD-B MceHyb MiLK MIRCERA MOTIVATE MRX2834-001 MRX2834-1003 NAFLD Prevention NANT2017-01 Neptune NIMS NuSci Nutrinia GIFT-02 OBAD Otsuka 276 Otsuka 294 PAIH PINS PLUMM PKTx (IMP) R3R Reata 402-C-1603 SHP626-201 Target-Nash TIC-TOK UTOPIA Velphoro (Vifor) VOCAL VX19-147-101 VX19-NEN-801 VX21-147-301 WA42985 Zemplar
Study site
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Local (Emory or CHOA) CONNECT
Study site
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Subject's Study ID
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Treatment Arm
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Regimen A Regimen B
Please use the following Visit Names for the KiD-B Study.
NEPH = Children diagnosed with kidney disease of hypertension.
NBX = Children undergoing a diagnostic native kidney biopsy.
CKD Visit # = Children with Chronic Kidney Disease.
TXP = Children with active kidney transplant. Please specify 6 Month, 12 Month, 24 Month, or Indication #.
CTRL = Normal/Healthy Controls
Please use the box to the right to list the patients:
1. Blood Collection Time
2. Urine Collection Time
3. Initials (A-A or AAA)
4. Date of Birth
5. Gender
6. Fasting?
* must provide value
1. Initials (_ _ _)
2. Sex: M or F
3. Date of Birth
4. Woman of Childbearing Potential?: Yes or No
5. FSH Required? Yes or No
6. Race: Other or African American
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Visit Name/Timepoint
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Please type the visit name or timepoint as it would appear in the study protocol
If this sample was not collected on the exact Timepoint ID as described in the SOP, type in the exact Timepoint (i.e. I-C2D6 for Induction Cycle 2, Day 6)
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Please type the visit name as it would appear in the study protocol
Site Name: Code
Boston Children's Hospital: BCH
Children's Hospital Los Angeles: CHLA
Children's Healthcare of Atlanta/Emory: CHOAE
Mount Sinai: MSSM
Nationwide Children's Hospital: NCH
New York University: NYU
Collection Site
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Please provide the full name of the site at which the sample(s) were collected and processed
Date and Time of Sample Collection
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Now M-D-Y H:M
Expected Date and Time of Sample Collection
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Now M-D-Y H:M
Visit Kit Serial Number
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This text is being generated because this study has agreed to contribute samples to the Biorepository for future research. Please provide the subject's Full Name, MRN, and Date of Birth.
Please also submit a copy of the specific subject's signed consent and assent documents.
Subjects Full Name (First and Last)
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Subject's MRN
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Subject's Date of Birth (DOB)
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Plasma (Purple Top) Tube
* must provide value
Yes No
Number of Plasma (Purple Top) Tubes
* must provide value
1.0mL lavender EDTA tube
* must provide value
Yes
No
Number of 1.0mL lavender EDTA tubes
* must provide value
2mL EDTA (Lavender Top) Tube
* must provide value
Yes No
Number of 2mL EDTA (Lavender Top) Tubes
* must provide value
3mL EDTA (Lavender Top) Tube
* must provide value
Yes No
Number of 3mL EDTA (Lavender Top) Tubes
* must provide value
4mL EDTA (Lavender Top) Tube
* must provide value
Yes No
Number of 4mL EDTA (Lavender Top) Tubes
* must provide value
6mL EDTA (Lavender Top) Tube
* must provide value
Yes No
Number of 6mL EDTA (Lavender Top) Tubes
* must provide value
10mL EDTA (Lavender Top) Tube
* must provide value
Yes No
Number of 10mL EDTA (Lavender Top) Tubes
* must provide value
Plasma (White Top) Tube
* must provide value
Yes No
Number of Plasma (White Top) Tubes
* must provide value
Serum (SST or Red Top) Tube
* must provide value
Yes No
Number of Serum (SST or Red Top) Tubes
* must provide value
3.5mL Gold SST
* must provide value
Yes No
Number of 3.5mL Gold SST
* must provide value
4.0mL Gold SST
* must provide value
Yes No
Number of 4.0mL Gold SST
* must provide value
5.0mL Gold SST
* must provide value
Yes No
Number of 5.0mL Gold SST
* must provide value
8.5mL Gold SST
* must provide value
Yes No
Number of 8.5mL Gold SST
* must provide value
2.5mL Red SST
* must provide value
Yes No
Number of 2.5mL Red SST
* must provide value
2.0mL Red Serum Clot Activator Tubes
* must provide value
Yes No
Number of 2.0mL Red Serum Clot Activator Tubes
* must provide value
4.0mL Red Serum Clot Activator Tubes
* must provide value
Yes No
Number of 4.0mL Red Serum Clot Activator Tubes
* must provide value
1.2mL Red Serum Tubes
* must provide value
Yes No
Number of 1.2mL Red Serum Tubes
* must provide value
Serum (SST/Red and Gray Top) Tube
* must provide value
Yes No
Number of Serum (SST/Red and Gray Top) Tubes
* must provide value
Mononuclear Cell Preparation (CPT for PBMCs) Tube
* must provide value
Yes No
Number of Mononuclear Cell Preparation (CPT for PBMCs) Tubes
* must provide value
PaxGene DNA (Black or Blue Top) Tube
* must provide value
Yes No
Number of PaxGene DNA (Black or Blue Top) Tubes
* must provide value
PaxGene RNA (Red Top) Tube
* must provide value
Yes No
Number of PaxGene RNA (Red Top) Tubes
* must provide value
Sodium Citrate (Light Blue Top) Tube
* must provide value
Yes No
Number of Sodium Citrate (Light Blue Top) Tubes
* must provide value
Sodium Heparin (Dark Green Top) Tube
* must provide value
Yes No
Number of Sodium Heparin (Dark Green Top) Tubes
* must provide value
Serum Separator (SST/Gold Top) Tube
* must provide value
Yes No
Number of Serum Separator (SST/Gold Top) Tubes
* must provide value
Plasma (Sodium Fluoride/Grey Top/Purple Top with White Ring) Tube
* must provide value
Yes No
Number of Plasma (Sodium Fluoride/Grey Top/Purple Top with White Ring) Tubes
* must provide value
P100 (Plasma/Clear Top) Tube
* must provide value
Yes No
Number of P100 (Plasma/Clear Top) Tubes
* must provide value
Acid Citrate Dextrose (ACD/Yellow Top) Tube
* must provide value
Yes No
Number of Acid Citrate Dextrose (ACD/Yellow Top) Tube
* must provide value
Streck Cell-Free DNA BCT (Yellow/Black Tiger Top) Tube
* must provide value
Yes No
Number of Streck Cell-Free DNA BCT (Yellow/Black Tiger Top) Tubes
* must provide value
Streck Cyto-Chex BCT (Purple/Black Tiger Top) Tube
* must provide value
Yes No
Number of Streck Cyto-Chex BCT (Purple/Black Tiger Top) Tubes
* must provide value
Insulin (MiniCollect) Tube
* must provide value
Yes No
Number of Insulin (MiniCollect) Tubes
* must provide value
Urine Cup
* must provide value
Yes No
Number of Urine Cups
* must provide value
PLUMM 3mL EDTA (DNA) Collection
* must provide value
Yes No
PLUMM 3mL EDTA (DNA) Time of Collection
* must provide value
Now M-D-Y H:M
PLUMM 6mL EDTA (PLA) Collection
* must provide value
Yes No
PLUMM 6mL EDTA (DNA) Time of Collection
* must provide value
Now M-D-Y H:M
PLUMM PAXgene (RNA) Collection
* must provide value
Yes No
PLUMM PAXgene (RNA) Time of Collection
* must provide value
Now M-D-Y H:M
PLUMM Urine Collection
* must provide value
Yes No
PLUMM Urine Collection
* must provide value
PLUMM First Morning Urine Collection Time (if applicable)
Now M-D-Y H:M
PLUMM VAMS Collection
* must provide value
Yes No
PLUMM VAMS timepoint(s)
* must provide value
PLUMM VAMS time(s) of collection
* must provide value
Urine Collection Jug
* must provide value
Yes No
Number of Urine Collection Jugs
* must provide value
Stool (ParaPak Container)
* must provide value
Yes No
Number of Stool (ParaPak) Containers
* must provide value
Biopsy (Saline or RNA Later)
* must provide value
Yes No
Number of Biopsy (Saline or RNA Later) Samples
* must provide value
Biopsy (in Formalin Fixed Paraffin Embedded Block)
* must provide value
Yes No
Number of Biopsy (in Formalin Fixed Paraffin Embedded Block) Samples
* must provide value
Saliva (Salivette)
* must provide value
Yes No
Saliva (Oragene)
* must provide value
Yes No
Number of Saliva (Salivette) Samples
* must provide value
Oropharyngeal (OP) Swab
* must provide value
Yes No
Number of Oropharyngeal (OP) Swabs
* must provide value
BloodSpot Card
* must provide value
Yes No
Number of BloodSpot Cards
* must provide value
Cerebrospinal Fluid (CSF)
* must provide value
Yes No
Number of Cerebrospinal Fluid (CSF) Samples
* must provide value
Tissue Slide Folder
* must provide value
Yes No
Number of Tissue Slide Folders
* must provide value
Blue Charged Slides
* must provide value
Yes No
Number of Blue Charged Slides
* must provide value
Hybridoma (In CryoVial)
* must provide value
Yes No
Number of Hybridoma (In CryoVial) Samples
* must provide value
Myeloma (In CryoVial)
* must provide value
Yes No
Number of Myeloma (In CryoVial) Samples
* must provide value
Serum separator monovette tube
* must provide value
Yes
No
Number of serum separator monovette tubes
* must provide value
Sodium citrate (blue top) monovette tube
* must provide value
Yes
No
Number of sodium citrate (blue top) monovette tubes
* must provide value
2.0mL lavender EDTA tube
* must provide value
Yes
No
Number of 2.0mL lavender EDTA tubes
* must provide value
2.0mL lavender EDTA tube + 2 slides
* must provide value
Yes
No
Number of 2.0mL lavender EDTA tubes + 2 slides
* must provide value
5.0mL Cyto Chex (Black/Purple Top) Tubes
* must provide value
Yes
No
Number of 5.0mL Cyto Chex (Black/Purple Top) Tubes
* must provide value
QFT TB Gold Plus tubes
* must provide value
Which blood tubes were collected?
* must provide value
Which blood tubes were collected?
* must provide value
Urine collected:
* must provide value
Local labs collected:
* must provide value
Is there a plasmapheresis sample to aliquot?
* must provide value
Yes No
Samples processed for Quest:
DOB (MM-YYYY)
* must provide value
Did the subject perform intense physical activity before blood collection?
* must provide value
Yes
No
Is the subject currently treated with Hemlibra/Emicizumab?
* must provide value
Yes
No
Mark subject's fasting status:
* must provide value
Fasting
Non-fasting
Joint Health Marker (Red Top) tubes
* must provide value
Yes
No
Number of Joint Health Marker (Red Top) tubes
* must provide value
Date and time of sample collection
Now D-M-Y H:M
VWF Antigen, VWF Activity and D-dimer (Blue Tops) tubes
* must provide value
Yes No
Number of VWF Antigen, VWF Activity and D-dimer (Blue Top) tubes
* must provide value
Date and time of collection
* must provide value
Now D-M-Y H:M
FVIII Inhibitor, Prior to Factor (Blue Top) tubes
* must provide value
Yes No
Number of FVIII Inhibitor - Prior to Factor (Blue Top) tubes
* must provide value
Date and time of collection
* must provide value
Now D-M-Y H:M
FVIII Inhibitor, 15-30min post (Blue Top) tubes
* must provide value
Yes
No
Number of FVIII Inhibitor, 15-30 min post (Blue Top) tubes
* must provide value
Date and time of collection
* must provide value
Now D-M-Y H:M
FVIII Inhibitor, 2H post (Blue Top) tubes
* must provide value
Yes No
Number of FVIII Inhibitor, 2H post (Blue Top) tubes
* must provide value
Date and time of collection
* must provide value
Now D-M-Y H:M
FVIII Inhibitor, 4H post (Blue Top) tubes
* must provide value
Yes No
Number of FVIII Inhibitor, 4H post (Blue Top) tubes
* must provide value
Date and time of collection
* must provide value
Now D-M-Y H:M
FVIII Epitope Mapping (Blue Top) tubes
* must provide value
Yes No
Number of FVIII Epitope Mapping (Blue Top) tubes
* must provide value
Date and time of collection
* must provide value
Now D-M-Y H:M
Batch Selection (Blue Top) tubesonly Group I ITI patients on Nuwiq/Octanate/Wilate
* must provide value
Yes No
Number of Batch Selection (Blue Top) tubes
* must provide value
Date and time of collection
* must provide value
Now D-M-Y H:M
F8 Gene Mutation (Purple Top) tubes
* must provide value
Yes No
Number of F8 Gene Mutation (Purple Top) tubes
* must provide value
Date and time of collection
* must provide value
Now D-M-Y H:M
TGA Analysis (White Top) tubesKeep at 4C
* must provide value
Yes No
Number of TGA Analysis (White Top) TubesKeep at 4C
* must provide value
Date and time of collection
* must provide value
Now D-M-Y H:M
APC (Green Top) tubesKeep at 4C
* must provide value
Yes No
Number of APC (Green Top) tubesKeep at 4C
* must provide value
Date and time of collection
* must provide value
Now D-M-Y H:M
CONNECT study: are you shipping frozen, processed aliquots?
* must provide value
Yes No
CONNECT study: tracking number
* must provide value
CONNECT study: Technician name
* must provide value
Processing start time
* must provide value
Now M-D-Y H:M
Processing end time
* must provide value
Now M-D-Y H:M
CONNECT study: number of PLA aliquots
* must provide value
CONNECT study: number of PBMC aliquots
* must provide value
CONNECT study: number of DNA aliquots
* must provide value
CONNECT study: number of SER aliquots
* must provide value
CONNECT study: number of PAXgene tubes
* must provide value
Ship PAXgene and EDTA tubes?
* must provide value
Yes No
Ship plasma and urine aliquots?
* must provide value
Yes No
Date to ship ambient samples
* must provide value
Today M-D-Y
Date to ship refrigerated samples
* must provide value
Today M-D-Y
Date to ship frozen samples
* must provide value
Today M-D-Y
Please use the adjacent text box to indicate which samples you are requesting to be retrieved from storage.
Please provide detailed information for each sample that you are requesting. This should include Study Name, Subject ID, Visit ID, Date, Sample Type, and Number of Aliquots Needed.
* must provide value
Please use the adjacent text box to indicate which samples you are requesting to be retrieved from storage to ship.
Provide detailed information for each sample that you are requesting. This may include Study Name, Subject ID, Visit ID, Date, Sample Type, and Number of Aliquots Needed.
Include recipient information:
Recipient Name
Address
Phone number
Email (for tracking notifications)
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Please use the adjacent text box to indicate the type and the number of samples you are requesting.
If necessary, you can also provide additional details about the types of samples you are requesting. This can include subject gender, age, race, ethnicity, and health status.
Sample type(s) requested
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Do you have a list of specific study IDs?
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Yes
No
Will these samples be used for device testing? If yes, provide device name.
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If a list is not provided, please indicate number of samples and any details to help us select samples for you (ct range, age, gender, etc).
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Have you checked OpenSpecimen to check if your requested samples are available?
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Yes
No
If samples from your list are not available, may we use our judgement to find a different sample of the same lineage and/or similar ct value?
* must provide value
Yes
No
Deadline to pull requested samples:
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Now D-M-Y H:M
Do you have any external documents that you would provide?
These may include lists or spreadsheets that provide information on the samples requested.
* must provide value
Yes No
Please use the adjacent link to upload any supporting documentation.
* must provide value
Please use the adjacent text box to indicate which supplies and/or kits that you are requesting.
Please provide details for all supplies and/or kits requested. For kit requests, please provide the visit name. For supply requests, please include number of tubes/collection supplies.
CONNECT study: please provide mailing address for CTDC to generate a shipping label.
* must provide value
FedEx Tracking Number (if local drop off, type LOCAL):
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Are any collected samples being contributed to the RADx Biorepository?
* must provide value
Yes
No
Please select all samples that are being contributed to the RADx Biorepository:
* must provide value
Sample drop-off location
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Please provide any additional information that will assist the CTDC staff in processing your request.