Download form - Hartwig Medical Foundation

Application form for sequencing of a study cohort
Name applicant:
Department:
Senior researcher/head of department:
Center:
Address:
Email:
Direct telephone number:
Project within a research consortium / current research cooperation?
If appropriate, name(s) involved researcher(s) and center(s):
Yes / No*
* delete as appropriate
Does the cohort satisfy the requirements for sequencing?
- Fresh-frozen tissue or tumor DNA from fresh-frozen tissue available?
- Tumor percentage in available tissue >30%?
- Paired germline DNA available for all patients (normal tissue/blood)?
- Clinical data available for recording in the HMF database?
- Cofinancing for sequencing available?
Organization:
Sum**:
Yes / No*
Yes / No*
Yes / No*
Yes / No*
Yes / No*
€
* delete as appropriate
** As indication; the amount of cofinancing should match the variable costs of sequencing, i.e. the costs of
reagents/chemicals.
Description of cohort
Tumor type:
Primary/locally advanced/metastatic*
Number of patients (biopsies and blood/normal tissue):
Collected in the period (from-to):
Collected as a part of a clinical trial?
If appropriate, please specify …
Systemic treatment started after collection of tissue?
If appropriate, please specify …
Clinical data regarding tumor type en outcome to treatment available?
If appropriate, please specify …
* delete as appropriate
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Yes / No*
Yes / No*
Yes / No*
Aim of sequencing for scientific research
Research question:
Short methodological outline:
Short outline of data analysis:
Importance for the HMF database:
To be completed by the Hartwig Medical Foundation
Costs:
Sample prep
Sequencing
IT-pipeline
Data storage
Data curation (clinical data)
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Version 3- 28/03/2017