Letter of Intent Application to the St. Louis Breast Tissue Registry If you are human, leave this field blank. Section 1: Application to the St. Louis Breast Tissue Registry Principal Investigator * Title * Institution * Department * Address * Address Line 2 City * State * AL AK AR AZ CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MH MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Postal Code Email * Phone Number * Fax Number * Financial/Administrative Contact * Tumor Description 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: Funding Information 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 Aims/Hypothesis 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 * This form is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply. Submit