Letter of Intent

Application to the St. Louis Breast Tissue Registry

If you are human, leave this field blank.

Principal Investigator *

Title *

Institution *

Department *

Address *

Address Line 2

City *

State *

Postal Code

Email *

Phone Number *

Fax Number *

Types of tumors requested *

Invasive

Carcinoma in situ

Normal

Other considerations (tumor size, age, length of follow-up, etc.)

How many cases are needed for this study? *

Number of sections? *

Size of sections in microns? *

Requested date for receipt of tissue: *

Other special requirements:

Is this research sponsored from a grant? If so, check box and please state source and funding period.

Please check if this research is sponsored from a grant.

Source

Funding Period

If not Funded by a grant, Please state how specimens will be paid

Write aims and hypothisis for proposed research *

Rationale *

Statistical justification for the number and type of cases requested *

Describe the technical approach *

Please assure the review committee that the proposed measurement technique(s) can be use on paraffin-embedded specimens *

Specify clinical/outcome data required *

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