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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 Page 1 of 2 Version 3- 28/03/2017 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) Page 2 of 2 Version 3- 28/03/2017