Application Title
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If applicable, please match the biosample request title to the title for the corresponding existing or planned grant application.
Today M-D-Y began collecting 1/30/2024
First Name
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Last Name
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Email Address
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Phone Number
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Institutional Affiliation
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Institutional Street Address
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Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Country
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Zip Code
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Your institution is considered:
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For profit
Not-for-profit
Biographical Sketch
Would you like to submit additional Biographical Sketches?
Yes
No
Biographical Sketch
Please describe the nature of your collaboration with the additional investigator whose biosketch is provided:
Would you like to submit additional Biographical Sketches?
Yes
No
Biographical Sketch
Please describe the nature of your collaboration with the additional investigator whose biosketch is provided:
Would you like to submit additional Biographical Sketches?
Yes
No
Biographical Sketch
Please describe the nature of your collaboration with the additional investigator whose biosketch is provided:
Would you like to submit additional Biographical Sketches?
Yes
No
Biographical Sketch
Please describe the nature of your collaboration with the additional investigator whose biosketch is provided:
NCRAD iPSC Replacement Policy:
There are no replacements for iPSC samples, except under the following circumstances:
1) iPSCs arrive physically compromised due to shipping issues: The iPSCs arrive physically compromised at their destination (e.g. thawed). A replacement is requested via email (iugbship@iu.edu) within 24 hours of receipt detailing how the samples were compromised during shipping. iPSCs that are physically compromised during shipping will be replaced at no charge.
2) Trained Customer/Investigator Requests: The customer requests a replacement for any reason other than being physically compromised during shipping, and Indiana University Genetics Biobank (IUGB) determines that the investigator has adequate experience and/or training in culturing iPSCs. In this situation, Customers/Investigators may be requested to submit documentation of training such as a certificate of completion for a training course in handling iPSCs. In this circumstance, the replacement iPSCs may be provided at a discounted rate.
I have read and agree to the terms and conditions provided in the NCRAD iPSC Replacement Policy.Â
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Yes No
Please indicate your experience working with iPSCs :
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Prior proficiency working with iPSCs (have established experience, such as publications)
Moderate experience working with iPSCs
Completion of an iPSC training course
No prior experience
Prior proficiency working with iPSCs (have established experience, such as publications)
Moderate experience working with iPSCs
Completion of an iPSC training course
No prior experience
Please indicate if you are applying for LCLs or iPSCs
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LCLs
iPSCs
Please upload the list of samples requested
Do you know the lines you want?
Yes
No
Please tell us about the sample criteria you are looking for (example: familial lines, sporadic lines, disease state you wish to study).
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Would you prefer to enter the IUGB Identifier of the lines you want, or upload a file of the lines you want?
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Enter lines
Upload file
For iPSCs, please provide the IUGB Identifier and number of vials for each line requested in your upload. For LCLs, please provide the sequence number and number of vials for each line requested in your upload.
Please provide the IUGB Identifier of the line requested.
How many vials of this line?
Do you wish to request another line?
Yes
No
Please provide the IUGB Identifier number of the line requested.
How many vials of this line?
Do you wish to request another line?
Yes
No
Please provide the IUGB Identifier of the line requested.
How many vials of this line?
Do you wish to request another line?
Yes
No
Please provide the IUGB Identifier of the line requested.
How many vials of this line?
Do you wish to request another line?
Yes
No
Please provide the IUGB Identifier of the line requested.
How many vials of this line?
Do you wish to request another line?
Yes
No
Please provide the IUGB Identifier of the line requested.
How many vials of this line?
Do you wish to request another line?
Yes
No
Please provide the IUGB Identifier of the line requested.
How many vials of this line?
Do you wish to request another line?
Yes
No
Please provide the IUGB Identifier of the line requested.
How many vials of this line?
Do you wish to request another line?
Yes
No
Please provide the IUGB Identifier of the line requested.
How many vials of this line?
Do you wish to request another line?
Yes
No
Please provide the IUGB Identifier of the line requested.
How many vials of this line?
Do you wish to request another line?
Yes
No
Please provide the IUGB Identifier of the line requested.
How many vials of this line?
Do you wish to request another line?
Yes
No
Please provide the IUGB Identifier of the line requested.
How many vials of this line?
Do you wish to request another line?
Yes
No
Please provide the IUGB Identifier of the line requested.
How many vials of this line?
Do you wish to request another line?
Yes
No
Please provide the IUGB Identifier of the line requested.
How many vials of this line?
Do you wish to request another line?
Yes
No
Please provide the IUGB Identifier of the line requested.
How many vials of this line?
Do you wish to request another line?
Yes
No
Please provide the IUGB Identifier of the line requested.
How many vials of this line?
Do you wish to request another line?
Yes
No
Please provide the IUGB Identifier of the line requested.
How many vials of this line?
Do you wish to request another line?
Yes
No
Please provide the IUGB Identifier of the line requested.
How many vials of this line?
Do you wish to request another line?
Yes
No
Please provide the IUGB Identifier of the line requested.
How many vials of this line?
Do you wish to request another line?
Yes
No
Please provide the IUGB Identifier of the line requested.
How many vials of this line?
Yes
No
Please provide a brief statement of research intent, such as text from the abstract of a funded grant.
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Do you currently have funding to support this research project?
Yes No
Letter of Support
Yes No
Today M-D-Y
Recipient Name:
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Street Address:
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Street Address Continued:
City:
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State:
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Zip Code:
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Invoice Recipient Name:
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Street Address:
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Street Address Continued:
City:
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State:
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Zip Code:
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Commercial Company ONLY: Date Sent MTA for review (before route application)
Today M-D-Y began collecting 4/24/2023
Commercial Company ONLY: MTA Review Prior to Routing to Stem Cell Team
Will not review MTA- knows will not be able to sign as is
Reviewed MTA and can confirm able to sign as is
Reviewed MTA and wants changes to MTA
Will not review MTA- knows will not be able to sign as is
Reviewed MTA and can confirm able to sign as is
Reviewed MTA and wants changes to MTA
began 4/18/24 for commercial companies
Date Began Routing MTA for approval:
Today M-D-Y began collecting 4/24/2024
Date of Stem Cell Team Determination of Application:
Today M-D-Y began collecting 4/24/2024