Certification of Use:
__________ (Initials)
I certify that all specimens provided by the NHLBI
Biologic Specimen Repository, or materials derived from said specimens, will be
used for research purposes only, in my laboratory only, at this institution
only, and only for the experiments proposed on this Request Form. Also, the
specimens or material derived from them will not be allowed to come into the
possession of any other persons except those engaged in research under my
direct supervision who accept these restrictions.
Assumption of Shipping Costs: __________
(Initials)
I agree to assume the cost of shipping specimens by
providing my FedEx (or other carrier) shipping account number, or by making
arrangements for prepaid shipments. I will confirm that the carrier is
certified to ship dangerous goods (biohazardous materials and dry ice) and can
pick up shipments from the NHLBI Biologic Specimen Repository. No shipments
will be made until my proposed shipping arrangements are accepted by the NHLBI
Biologic Specimen Repository.
Acknowledgment of Source: __________
(Initials)
I agree to acknowledge the NHLBI Biologic Specimen
Repository in all publications and presentations of studies utilizing specimens
received from said Repository. I also agree to provide copies of all
publications and abstracts of presentations to the appropriate branch of the
National Heart, Lung, and Blood Institute.
Abstract of Proposed Specimen Use (200-300
Words):
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