Thoracic Biorepository Sample Request Form Today's Date Specimen(s) Requested by: Principal Investigator Email Address Grant Number (Internal) Center Number (Vanderbilt Users Only) Purpose of your project / Your original research question: Biorepository Protocol Number if Known Rationale for the specimens requested and justification for the sample size: Shipping Address/Address Sample Types Serum (250 microliters) Plasma, EDTA (250 microliters) Plasma, Streck (250 microliters) Urine (5 mL) Lung Cancer Tissue (200 mg) Normal Lung Tissue (200 mg) Germline DNA (0.5 microgram) BAL supernatant (5 mL) BAL pellet (~2 microliters) Pleural fluid pellet (~2 microliters) Tissue Microarray Section (50-120 tumors in duplicate per section) Bronchial Brushings (1 brush= ~150,000 cells) Bronchial Biopsies (1 mm in diameter) Nasal Brushings (1 brush= ~300,000 cells) Buccal Brushings (1 brush= ~300,000 cells) Sputum (5 mL in Saccomano's fixative) If you chose multiple sample types, do you want matched samples (a set of each sample type per patient)? Yes No Tissue Type Malignant Normal Tissue Treated With Radiation Chemotherapy No Treatment Would you like normal matched tissue from the same patient(s)? Yes No Amount and Type of Sample Min to Max Size/Volume Preparation/Preservation of Specimen Fresh Frozen FFPE Are Clinical Data Elements Needed? Yes No If you require CDEs, please choose from the following: Gender Race Ethnicity BMI Smoking Status Age Started Age Quit PKY Number of Packs / Day Number of Years Asbestos Exposure Cancer History CT Date Nodule Size (mm) Nodule Location Margin Density PET Date PET SUV for the lesion Primary Tumor Location PFT Date FEV1 % Pred Clinical Stage Diagnosis Date Diagnosis Age Collection Date Age at Collection Histologic Type Path Stage Mutation Status Thoracotomy Date LDKA (Late Date Known Alive) Living Status Progression Date Progression Site Recurrence Date Recurrence Site Radiation Therapy Info Chemo Therapy Info Choose Your Affiliation Vanderbilt Academia External Academia Commercial