Manual Biospecimen Request Submission Form

NICHD DATA AND SPECIMEN HUB (DASH)
Biospecimen Request Submission Form
OMB Control Number: 0925-0744
Expiration Date: 07/31/2027

INSTRUCTIONS:
Fill out the following fields to the best of your ability. Hovering over each field will display a tool tip with
additional detail. For questions or clarification, contact [email protected]. Send the completed
form to SupportDASH. Following review, the Request Package supporting documentation – the
Biospecimen Request Form (BRF) and Material Transfer Agreement (MTA) – will be generated and sent to
the Requester. Review all documents before you obtain the necessary signatures. The Requester is
responsible for coordinating with all involved parties to collect the signatures required to complete the
request.
If you need to edit your request details after the Request Package has been generated, make these
changes in this form and resubmit it to SupportDASH. An updated Request Package will be generated. Do
not edit the content of the BRF or MTA, as all details must match between forms.
Note that if your funding is not yet available, you may reach out to SupportDASH to request a Letter of
Availability so you may apply for funding.
Additional guidance can be found on the DASH Tutorial and Request Resources pages.
All fields marked with an asterisk ( * ) are required.

Public reporting burden for this collection of information is estimated to average one hour per response, including the time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency
may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control
number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this
burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0744). Do not return the
completed form to this address.

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1. General
REQUESTED STUDY

REQUEST NAME
Request Name * (128 Characters)

REQUESTER INFORMATION
If you have an existing account in DASH, please enter your account information below. If you need to make
any updates to your DASH account, please go to Update My Profile.
Name *
Email Address *
Job Title/Position *
Institution *
Institution Type * For Profit
Institution Address *
School/Division/Center

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2. Study Information
Please fill out the fields below describing the study you are requesting biospecimens for.
REQUEST PROJECT TITLE *
Please enter a request project title that is less than 128 characters including spaces.

RESEARCH PLAN *
Please enter a research plan that is less than 1024 characters including spaces. Please provide a brief
description of the study to include study aims/goals, hypothesis that will be tested, methodology to be used,
and the expected outcomes. All acronyms must be spelled out at least once.

DESIGN AND ANALYSIS PLAN *
Please enter a design and analysis plan that is less than 1024 characters including spaces. In the description
please include specific aims, a short abstract of the design and analysis plan. All acronyms must be spelled
out at least once.

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FUNDING INFORMATION
Funding Status *
I have funding to pay for biospecimen
shipping, handling, and analysis

I am applying for funding for this
biospecimen request

Funding Source *
NIH Extramural

NIH Intramural

Other

Funding Institution(s) *
Enter the full name(s) of the funding institution(s) :

Funding Type *
Contract

Grant

Other

Funding Identifying Number *
Put “N/A” if unknown. If “Other”, please specify.

PRINCIPAL INVESTIGATOR (PI)
Identify a PI from the requesting institution. The PI may not be a student/fellow.
Name *
Email Address *
Job Title/Position *
Institution *
Institution Type *

For Profit

Institution Address *
School/Division/Center

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AUTHORIZED ORGANIZATIONAL REPRESENTATIVE (AOR)
Identify an AOR from the requesting institution. The AOR must have the authority to sign and enter into
agreements on behalf of the institution. Additional details can be found in the DASH Guide for Authorized
Organizational Representative (AOR)/Signing Official.
Name *
Email Address *
Job Title/Position *
Institution *
Division

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Selected Biospecimens
Biospecimen Availability Disclaimer
The biospecimen catalog provided in DASH is based on biospecimen availability at the time of request.
NICHD DASH cannot guarantee the type, quality, or amount of biospecimens available in the NICHD
Contracted Biorepository. Biospecimens will be available on a first come first served basis. Biospecimens
will be shipped to the Requester based on terms and requirements stated in the NICHD DASH Policy. All
biospecimen related transactions must be made directly with the NICHD Contracted Biorepository.

BIOSPECIMENS BEING REQUESTED *
Enter the quantity and volume/amount for each specimen type being requested. The final sample
list may be selected from the master inventory via communication with SupportDASH.
Specimen Type

Quantity Needed

Amount Needed (per sample)

Price Disclaimer
Prices to obtain biospecimens through DASH will vary dependent on costs for processing, aliquoting,
shipping and handling. Exact price will be finalized by the NICHD Contracted Biorepository after your
biospecimen request has been approved by the DASH Biospecimen Access Committee. Once approved,
all transactions for fulfilling your request will be made directly by the NICHD Contracted Biorepository.

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