IDI Sample Record Destruction Form

IDI SAMPLE DESTRUCTION AUTHORIZATION FORMThis form is to be used to approve and record the disposal and destruction of biologic samples from clinical trialsName of Trial:Clinical Trial Number:Person Making Request:Position/Title:Email:Telephone:Signature:Date:Please verify that samples can be destroyed1. The samples destruction is compliantwith the Informed Consent? yes no N/A2. The samples have been analysedas outlined in the study protocol? yes no N/A3. The samples destruction is compliantwith the activities outlined for the endof of study? yes no N/A4. Have the samples satisfied the minimumRetention requirements? yes no N/A5. Samples have been de-identified fromContaining any patient identifyinginformation? yes no N/AIf NO or N/A has been selected for any of the above, an explaination must be provided in the section here:IDI Samples Destruction Form v1 P a g e | 1

Sample DetailsType ofSample(blood,plasma,urine,etc)NumberofSamples(total # ofsamples)DescriptionMethod ofdisposal/destruction(specify any important handlinginstructions; if samplesdestroyed by third-party,indicate)If required, attach a list (e.g manifest, Excel sheet) of all individual samples to bedestroyedResearch Office ApprovalBased upon the information provided above, the samples can be destroyed.yesnoIf NO provide reason:Name:Signature:Position:Date:IDI Samples Destruction Form v1 P a g e | 2