Anatomy Bequest Program

Course Access Proposal

If the requestor is submitting this proposal on the behalf of another organization, state the name of the other organization.

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.

Please upload your syllabus here.

Include anticipated frequency (i.e. annually, monthly, sporadically).

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 Course Event Request will be required of subsequent courses/course events held in Jackson Hall. A Transfer Request will be required for subsequent courses/course events held at external schools/organizations.

What building and room number is the lab located?

How many whole body, undissected, donors are you requesting?

How many whole body, previously dissected, donors are you requesting?

List info which is preferred but not absolutely necessary for the scheduling of your course. Prioritizing these preferred attributes will increase the likelihood of fulfilling your request.

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.

(i.e. brains, spinal cords, disarticulated joints, organs, etc.) Please note these specimens have additional fees associated with them.

Please note that use of teaching models and teaching collection is $100 per course-per term.

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.

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 courses.

If you have any special requests or need us to know any additional information please add it here.

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.

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.

An electronic signature is the form of your typed name and/or attached digital signature will be as valid as an originally signed consent.