Material Transfer Registration Form
This material transfer registration sheet must be completed for any requests for stool, nucleic acid or bacterial
specimens. PLEASE NOTE: INCOMPLETE MATERIAL TRANSFER REGISTRATION SHEETS WILL NOT BE REVIEWED. If
more space is required, please attach additional pages.
Contact details (* required)
Name*:
______________________________________________
Title:
______________________________________________
Institution*:
______________________________________________
Address:
______________________________________________
______________________________________________
______________________________________________
______________________________________________
Ph:
______________________________________________
Email*:
______________________________________________
Requesting specimens from (select all that apply):
_____ GEMS-1
_____
GEMS-1A
_____
No Preference
Version Date: 20 October 2015 Page 1
Materials requested (Please mark material with a check [X] and indicate the number of strains):
Bacteria
______ Diarrheagenic E. coli
______ Number of strains
If you would like particular pathotypes, please indicate below.
______ ETEC
______ Number of strains
______ EAEC
______ Number of strains
______ Typical EPEC
______ Number of strains
______ Atypical EPEC
______ Number of strains
______ EHEC
______ Number of strains
______ Shigella spp.
Please indicaate whether you would like
bacterial strains from:
______Cases only
______Controls only
______Cases or controls
______ Number of strains
If you would like particular species, please indicate below.
______ S. flexneri
______ Number of strains
______ S. sonnei
______ Number of strains
______ S. boydii
______ Number of strains
______ S. dysenteriae
______ Number of strains
______ Salmonella spp.
______ Number of strains
______ Campylobacter
______ Number of strains
______ Vibrio spp.
______ Number of strains
______ V. cholerae
______ Aeromonas spp.
______ Number of strains
______ Number of strains
Comments (If requesting known specimen ID # please attach a list):
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
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Stool
______ Stool.
Number of stool specimens:_____
Harboring particular pathogens (Y or N)?
Mass of stool per specimen:_____ g
_____
If so, which pathogen(s)? ________________________________________________________
Please indicate if you are requesting stool from cases and/or controls:
Cases only?
____
Controls only?
____
Cases and matched controls?
____
Comments (If requesting known specimen ID # please attach a list):
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Nucleic acids
______ Nucleic acids.
Number of specimens:_____
Mass of nucleic acid requested:_____µg
Containing nucleic acids from particular pathogens (Y or N)?
______
If so, which pathogen(s)? ______________________________________________________
Please indicate if you are requesting stool from cases and/or controls:
Cases only?
____
Controls only?
____
Cases and matched controls?
____
Comments (If requesting known specimen ID # please attach a list):
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
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Please provide a brief description of the purpose of your request. If requesting, nucleic acid, stool or > 25 bacterial
specimens, please also complete a Concept Sheet for GEMS Specimens.
Purpose:______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Please provide a brief description of your microbiological experience and resources available to perform the
proposed work using these isolates.
Experience and
Resources:____________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Are you interested in pursuing a collaboration with any GEMS investigators (Yes or No)? _____________
If yes, which investigators (Please name)?___________________________________________________
Co-ordinating institution (UMB)
PI: Myron M. Levine (UMB)
Co-PI (clinical): Karen Kotloff (UMB)
Co-PI (microbiology): James Nataro (presently at UVA)
Statistics: William Blackwelder (UMB)
Epidemiologists: Dilruba Nasrin (UMB)
Field investigators
Farah Qamar (AKU, Pakistan)
Thandavarayan Ramamurthy (NICED, India)
ASG Faruque (ICDDR,B, Bangladesh)
Samba Sow (CVD-Mali, Mali)
Jahangir Hossain (MRC
Pedro Alonso (CISM, Mozambique)
Robert Breiman (CDC-Kenya)
Version Date: 20 October 2015 Page 4
I acknowledge the following:
- That the GEMS Executive Committee and GEMS site investigators have worked for many years to generate the
GEMS data.
- That I will not receive specimens with any personal identification codes, nor be provided with any link that
might potentially identify the individual subjects enrolled in GEMS and their families and the communities from
whom data were collected.
- That I will provide import permits where necessary, pay for shipping and pay for costs incurred to University of
Maryland when preparing and sending the Materials. (NOTE: Until September 30th 2016, University of
Maryland will not charge the recipient for the cost of preparing materials. However, the recipient will be
expected to pay for shipping costs. After September 30th 2016, a nominal fee will be charged to the recipient to
cover the cost of preparing materials. The recipient will be expected to pay for shipping costs. University of
Maryland will make every effort to ship Materials at room temperature, if possible, to reduce shipping costs).
Signature: ________________________________________
Date:_____________________________________
Version Date: 20 October 2015 Page 5