Eli Lilly Samples Biorepository Request Form » Myology Institute » College of Medicine

Eli Lilly Sample Biorepository Request Form

Please note this form is for samples banked from the Eli Lilly Clinical Trial. If you are requesting any other samples a separate form must be completed.

Name of Requestor(Required)

First Last

Company/Organization(Required)

Email(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Proposed Study(Required)

Describe the intended use/ proposed study for the samples.

Sample Type Requested(Required)

Check all that apply

Plasma/Serum

DNA

RNA

Will you need access to the clinical data (if available)?(Required)

Yes

Samples Requested-Description(Required)

Provide a description of the samples you are requesting such as sample type, time points (single vs multiple), volume needed, and any clinical data requested (if available).

Benefits to patients/ Duchenne community(Required)

Describe the potential benefits to the patients who contributed these samples and/or the Duchenne community and related research field.

Are you willing to share your results?(Required)

Yes

Maybe; Conditions Apply

If No or Maybe, please describe any restrictions