Genomics of MPNST (GeM) Consortium: Application

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Date of Submission*

Institution/Affiliation*

Contact Information

Principal Investigator: Name, Credentials*

PI Contact: Email*

PI Contact: Phone*

PI Medical Specialty*

Please attach Principal Investigator's biosketch with personal statement to describe investigator's role with MPNST*

Please attach PI's biosketch here

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Research Coordinator: Name (if applicable)

Research Coordinator: Email

Research Coordinator: Phone

Primary Contact: Name (if other than PI or Research Coordinator)

Primary Contact: Email

Primary Contact: Phone

Steering Committee Representation*

The GeM Consortium is dedicated to shared decision making among member institutions. Would you like to have a representative from your site serve on the Steering Committee?

Yes

No

Steering Committee Representative (Name)

If yes, please indicate who will be serving as your site representative:

IRB Considerations

Does your institution have an active IRB protocol that permits tumor banking? (Note: tumors will be banked at each institution)*

Yes

No

Does your IRB protocol allow for the collection of clinical data to match genomic data?

Yes

No

Does your IRB protocol allow for whole genome analysis of tumor specimens with paired normal?

Yes

No

Does your IRB protocol allow for sharing of clinical and genomic data in a web-based database?

Yes

No

MPNST Collection

Who will be consenting patients, collecting clinical data, and tracking/shipping specimens for the GeM Consortium? (Name, Email)*

Approximately how many patients with high grade, NF1-related MPNSTs have been treated at your institution during each of the last three years?*

Please provide an estimate for 2014, 2015, and 2016:

Approximately how many patients with high grade, sporadic MPNSTs have been treated at your institution during each of the last three years?*

Please provide an estimate for 2014, 2015, and 2016:

Of the patients seen with NF1-related and sporadic MPNST, how many have clinical records for at least one year of follow-up after diagnosis?

Does your institution have retrospectively collected, fresh frozen MPNST specimens with paired normal available for use in the consortium?*

Yes

No

If yes, how many fresh frozen NF1-related MPNST are available?

If yes, how many fresh frozen sporadic MPNST are available?

Does your institution have retrospectively collected FFPE MPNST specimens available for a centralized pathology review by the consortium?*

Yes

No

If yes, how many FFPE NF1-related MPNST are available?

If yes, how many FFPE sporadic MPNST are available?

Please name an individual at your institution (and provide their email) from each of the following disciplines:

Medical Oncology (name, email)*

Pathology (name, email)*

Surgical Oncology (name, email)*

Neurofibromatosis specialist (name, email)

I confirm that each person listed in this form is aware of the GeM Consortium and provision of their contact information for the purpose of this application.

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