Vector Request Form

Vector Request Form

PROJECT INFORMATION

Each product requires a separate form to be completed. Any information not known at this time may be left blank or listed as TBD, to be completed when requested at a later time.

Sponsor Name*

First and Last Name of Project Sponsor

Sponsor Title

Phone Number*

Email*

Institution / Company Name*

Department Name

Institution Address*

Business Type*

Non-Profit

For-Profit

Sponsor Contact 1*

Name of person authorized to communicate on behalf of the sponsor.

Email Contact 1*

Sponsor Contact 2

Name of person authorized to communicate on behalf of the sponsor.

Email Contact 2

Sponsor Contact 3

Name of person authorized to communicate on behalf of the sponsor.

Email Contact 3

Current Phase of Drug Development*

Research

Pharm/Tox

Clinical

Clinical Application / Disease*

Regulatory Status / IND number

Vector Administration

Indicate how the vector will be administered or used in the clinical study.

PRODUCT INFORMATION

Any information not known at this time may be left blank or listed as TBD, to be completed when requested at a later time.

Vector Type*

AAV

LNP

Serotype / Pseudotype*

Select from the dropdown list; if not listed, please select 'Other' and provide in the next section.

Select

Serotype / Pseudotype (Other)

Grade*

Choose DEV for Pilot Run, GLP for Pharm/Tox, and GMP for Clinical Studies.

DEV

GLP

GMP

Vector Name*

Limit to 10 characters total (including spaces): i.e. AAV2-EGFP2.

Transgene Name*

Is AAV vector self-complementary?*

Yes

Desired Vector Titer (vg/mL or TU/mL)*

Use vg/mL for AAV (i.e. 5e12 vg/mL) and TU/mL for LV (i.e. 5e8 TU/mL).

Vial Type*

AT-Closed vial is the default for GMP product fill. Nalgene Cryovial is available as alternative for additional cost. Nalgene Cryovial is the default for DEV and GLP fill. AT-Closed vial is available as alternative for additional cost.

AT-Closed Vial 1.0 mL

Nalgene Cryovial 1.0 mL

Desired fill volume per vial (mL)*

Indicate from 0.25 to 1.0 mL

Number of vials*

Indicate the minimum number of vials required (up to 400 AT-Closed Vials or 500 Nalgene Vials for GMP product). Includes vials for release testing, retains, and stability (if applicable).

Where will the product be filled?*

CHOP

Sponsor CMO

Will long-term stability testing be required?*

Yes

TBD

Will AAV diluent (excipient) be required?

If yes, indicate number of vials (1 mL/vial). For LV indicate NA.

Additional Comments:

Provide any additional information about your product or project (optional)

PLASMID INFORMATION

Provide the exact plasmid name(s) as listed on the plasmid map(s). If a name exceeds 12 characters, an abbreviated name will be used on CHOP records. The sponsor is responsible for ordering and providing the transgene plasmid to CHOP, and any non-standard capsid plasmid not available at CHOP. For plasmid requirements, consult with CHOP on the amount, specifications and vialing configuration required.

Transgene Plasmid Name*

Limit to twelve (12) characters (including spaces)

Will sponsor provide capsid/envelope plasmid?*

CHOP standard plasmids include AAV1, AAV2, AAV5, AAV6, AAV8, AAV9 plasmid and VSV-G plasmid

Select or enter value

Provide capsid/envelope plasmid name*

Limit to twelve (12) characters (including spaces)

Will sponsor provide helper plasmid?*

CHOP standard helper plasmid is available

Select or enter value

Helper Plasmid Name

Limit to twelve (12) characters (including spaces)

Will sponsor provide Rev plasmid?*

CHOP has standard Rev plasmid available

Select or enter value

Rev Plasmid Name

Limit to twelve (12) characters (including spaces)

Plasmid Information: Additional Comments

List any additional sponsor-provided plasmid names (if not already provided above), or any comments regarding plasmid.

Name of Person Submitting the Form*

Email Address*

Please be advised that submission of this form constitutes approval and acceptance of all criteria outlined above

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