ALL SPECIMEN REQUESTS MUST BE HANDLED THROUGH THE OOAS.

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1 1 Anatomic Specimen Request University of Pittsburgh School of Medicine Department of Neurobiology And Office for Oversight of Anatomic Specimens (OOAS) NOTE: If fetal tissue is required STOP - please do not complete this form. All studies involving fetal tissue must be processed through the IRB and requests placed with an approved source. Please provide the following information. All signatures must be secured prior to release of cadavers through the Humanity Gifts Registry Program (HGR) or submission of a tissue request to an approved external supplier. Release of HGR cadavers is restricted to availability. Course Director/Principal Investigator: Position: Phone: Contact Person: Position: Phone: Department/Division: Cost Center/Account No.: Specify Type & Number of Specimens Requested: Male [ ] Female [ ] No preference [ ] Unpreserved [ ] Preserved [ ] Non-HGR Specimens: Supplier Name & Address: Phone Number: Note: ALL SPECIMEN REQUESTS MUST BE HANDLED THROUGH THE OOAS. The OOAS will process all required paperwork through the University of Pittsburgh or UPMC and will submit all orders to approved suppliers. Anatomic site(s) to be studied:

2 2 Purpose of Specimen Use please choose from the following: Education [ ] Clinical Training [ ] Research [ ] CME Credit Course [ ] Yes [ ] No Grant or Industry Sponsor(s): [ ] Yes* [ ] No Name of Sponsor: *NOTE: The involvement of company representatives (presence in the lab) is subject to the following requirements: Industry Relationships Policy (UPMC Policies HS-EC1702) and Vendor Access Policy (HS- FM0222). Registration in VendorStat with the appropriate credentials. Registration is at: Completion of the Vendor Training module at CORID Approval No.: Description of course (including content and purpose), or study and procedures to be performed on specimen(s): (attach syllabus, course brochure or abstract) Type and number of participants (i.e., students, residents, fellows, faculty and invited external guests): Dates of Specimen Use: Begin End Location of Specimen Use: Scaife Hall, Room 360 or 375: [ ] Other EH&S* Approved Facility: [ ] Location: Where will specimens be stored? Type of storage (refrigerator or freezer): Will tissue be stored in the refrigerator or freezer with animal tissue? [ ] Yes [ ] No If yes, what measures will be taken to keep these tissues separate? *Environmental Health & Safety

3 3 1) It is understood and agreed that the person named above and all others listed on the attachment will not use or transport the specimen(s) identified above outside of the above-named facility nor use the specimen(s) for any purpose other than that described herein without prior written approval from the tissue source via the OOAS. 2) Taking photographs or making video recordings of cadavers/specimens requires prior written approval from the tissue source; this approval process must be coordinated through the OOAS. Please note that photographing or making video records of HGR cadavers/specimens is generally prohibited. 3) All human tissue should be treated as potentially hazardous material and, as such, it is acknowledged that all universal blood and bodily fluid barrier precautions shall be used during the conduct of the proposed activities. 4) It is understood and agreed that an appropriate acknowledgment of the source of any cadaveric tissue utilized will be included in any presentations or publications arising from this work. 5) For HGR specimens, it is agreed that the identification tag must remain attached to each cadaver at all times. I understand and agree to the above terms: Course Director/Principal Investigator Approved: Jan N. Hart Director, Humanity Gifts Registry Carolyn Louderback Administrator, Department of Neurobiology Shoshana A. Matusak, MSL Director, Office for Oversight of Anatomic Specimens Barbara E. Barnes, MD, MS Associate Dean for Continuing Medical Education, University of Pittsburgh School of Medicine Assistant Vice Chancellor for Continuing Education in the Health Sciences

4 4 Individuals Participating in Course or Study (Please begin with the PI or Course Director and then list ALL persons who will be present in the lab, including invited company representatives) Internal or External Tissue Name Title Participant* Dept./Division Phone No. Contact** * University of Pittsburgh or UPMC ** Person in attendance will handle the tissue either by performing surgical procedures, dissection or use of a medical device or needle)

5 5 HGR FEE STRUCTURE (For HGR Whole Cadavers/Specimens Only to be completed upon receipt and approval of preceding form pages and returned to Contact Person for Course Director/PI signature) The Humanity Gifts Registry Program (Department of Neurobiology), through the Office for Oversight of Anatomic Specimens, assesses a fee for the use of all donated cadavers for education, training and research. This cost recovery fee is intended to help offset administrative costs, as well as the cost of cadaver preparation and preservation, transportation, storage, cremation and burial or return of cremains to the family. An additional fee may be charged for any special preparation and/or consultation required by the training course or research study. Note: Fees are subject to change. Course Director/Principal Investigator: Department/Division: Fiscal Contact: Telephone Number: Cadavers Requested: Date Required: Preparation Required: Unpreserved [ ] Cost: Preserved [ ] Cost: Additional Preparation and/or Fees (Description): /hr. = Total Cost: Total to be Billed: I have reviewed the above costs and agree to provide payment at the time of cadaver release for the approved training course or research study. Course Director/Principal Investigator Date Cost Center/Account No. For internal use only: HGR Number(s): Revised: 2/17/2011 Revised 12/13/2013 Revised 12/20/2013 Revised 2/2/2016