Anatomy Bequest Program Access Proposal

Anatomy Bequest Program Access Proposal

Research, Clinical Skills Training, or Biomedical Design Request

Updated: June 2022

Today's Date*

Name of Requester*

Office Phone, Mobile Phone, Email*

Name of Requesting Organization*

Name of Sponsoring Organization, if applicable

If the requestor is submitting this proposal on the behalf of

another organization, state the name of the other organization.

Event Title*

Date(s) and Time(s) of Initial Event*

(Include anticipated frequency: i.e., sporadic, annual, monthly)

Once approved, each proposal is valid for five years. Recurring events with the same requestor, sponsor, event title, location, purpose, and anatomical material needs will not be required to submit a new proposal within that timeframe. A Research Event Request will be required for subsequent event.

Event Location*

Select

Name of Location

Such as APIC, ESS, etc.

Address of Location

Transportation Method

Select

Requestor Facilitated Transportation

Alternative transportation methods are occasionally permitted with prior approval. Please provide details regarding any proposed alternative transportation arrangements including the type of conveyance vehicle (i.e., hearse, ambulance, van, etc.) and who will be driving the vehicle.

* If on-campus: Please indicate if you/someone from your organization will be picking-up on foot.

Date and time of donor/specimen delivery to event location

This is when the donor/anatomical material will be delivered to the event location.

Date and time of donor/specimen pick up from event location

This is when the donor/anatomical material will be picked-up from the event location and returned to ABP.

Event/Transport Day Contact Information*

Please provide name and cell phone number of contact for the day of the event.

Event Participants*

Please include the name of the lead investigator and their information. State the number and professional association (i.e., biomedical engineers, physicians,paramedics) of the event participants.

Is this event exclusively for the purpose of training University of Minnesota staff, faculty, or students?*

Select

How will this event promote the advancement of medicine?*

What are your objectives?

List the diseases and/or conditions targeted by event.*

Does this request include performing vascular perfusion?*

Select

How many donors or specimens are you requesting?*

Preservation Status of Anatomical Material

Select

Anatomical Region(s) Requested*

Head, Neck, Thorax, Abdomen, Upper and/or Lower Extremities, Pelvis, etc.

Does this request require access to disarticulated anatomical specimens?

Select

If yes, please provide disarticulation instructions (i.e. mid-femur to mid-tibia/mid fibula).

Please be specific if there are structures that must be preserved or included in the disarticulation.

What procedures will the anatomical material undergo as part of this request?*

What are your required donor attributes?*

Please select and list any restrictions that are absolutely necessary for the success of the event. Also note that the more restrictions listed, the more difficult it may be to fulfill the request.

Select

Sex

Select

Weight Range

Age Range

Contraindicated Pathology

Required Pathology

Do you have any preferred donor attributes?

List any additional attributes which are preferred, but not necessary, for the success of the event.

Does this request require access to anatomical material from a donor with a postmortem interval of less than 48 hours?

If so, the access will likely need to occur before the donor’s full medical suitability assessment has occurred. Although an initial medical risk assessment screening will have occurred, the donor’s serology results and written medical records may not yet be available. This is a formal process called an Exceptional Release and is limited to neurological or other studies with high potential for tissue necrosis. An anatomical material distributed as part of this process has the potential to be later deemed as medically unsuitable such as in the event a donor’s serology results are positive for HIV or the hepatitis B or C viruses.

Select

Will you be retaining anatomical material?*

Does this request include the storage and use of anatomical material for a period longer than 30 days? Anatomical material does NOT include the following: urine, feces, semen, or other bodily fluids; tissue biopsies which will result in terminal processing through the research process; tissue samples taken for histological preparation, paraffin blocks, and tissue slides; human cells, hair, gallstones, kidney or bladder stones. Please note that any material kept for 30 or more days is considered a long term loan and will be subject to additional fees.

Select

What type of anatomical material will you be retaining and for what purpose?*

(Ex. disarticulated knee, on-going biomechanical testing)

Other Requests

List any other needs regarding donor preparation, laboratory set up, instrumentation, or accommodations. Please Note that ABP does not offer additional event staffing or anatomy consultation.

Does this request require the acquisition of images in the form of videography or photography to document scientific methodology? (This does not include Ultrasound, MRI, or Fluoroscopy.)*

If approved, we will create an Image Use Agreement, that will allow acquisition of images under strict stipulations.

Please note that we do not allow the use of Zoom, Microsoft Teams, etc. to live stream events.

Select

What type of imaging do you plan on using and for what reason?*

Please give a detailed description of what and why you will be obtaining images.

Additional Information

If needed please provide any additional information that we may need to know about this proposal.

Accounting Information*

This section must be completed in full.

Please indicate where, and to whom, invoices may be sent. Include an accounting reference number, PO, or chartstring where applicable. Leaving this blank may result in a delay in our ability to support this proposal or lead to incorrect invoicing.

Signature*

By signing this document, you are acknowledging that you have read and understand the requirements associated with tissue access.

Policies Regarding The Access To Human Anatomical Material:

1. Requesters must agree to the access terms as defined in the Anatomy Bequest Program Proposal Form (the “Proposal”). Access to Human Anatomical Material is only for the purpose described in the Proposal, and the Requester will assume all responsibility for such use.

2. Requester is responsible for making sure that each person with access to or knowledge of allocated Human Anatomical Material provided by the University complies with the provisions of this Agreement during the Term of Access, as defined in Section 1 of the Human Anatomical Material Access Agreement.

2.1 Requester must conduct an appropriate orientation, each course/study participant must sign a Human Anatomy Access Orientation Disclosure Form. The forms shall be maintained by the Requester and are subject to review at any time the Anatomy Bequest Program requests.

2.2 Requester will receive access to the Human Anatomical Materials as a loan from the University. Human Anatomical Material reimbursement fees are structured to compensate the University for expenses associated with the acquisition, preparation, tracking, storage and final disposition of whole body donors for use in medical education and research.

3. Appropriate respect and privacy of the donor must be maintained at all times during the time the Human Anatomical Material is being used by the Requester.

4. Acquiring photographs or video images of the Human Anatomical Material is strictly prohibited without the prior consent of the Anatomy Bequest Program Proposal Review Committee and requires an executed Image Use Agreement between the University and Requester documenting the purpose for the acquisition, scope of image distribution, method for storing the images, and the timeframe for disposition of any acquired images.

5. The Requester shall track all allocated Human Anatomical Material by keeping the donor’s acquisition number tag with the Human Anatomical Material at all times during the loan. If the tag becomes disassociated from the anatomical material, the University should be contacted immediately.

6. The custody of the Human Anatomical Material shall not be transferred to any user not approved by the Anatomy Bequest Program Proposal Review Committee.

7. The University will arrange for final disposition of all Human Anatomical Material. Human Anatomical Material received from the Anatomy Bequest Program shall not be disposed of as medical waste. All Human Anatomical Material received from University, must be returned to the Anatomy Bequest Program within the timeframe established in the Anatomy Bequest Program Proposal Form.

Signature

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