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We agree that the identification tags must remain attached to the body or body part at all times. The anatomical material will be returned on for final disposition by the Nebraska Anatomical Board. Signature of person requesting materials Department Chairperson s signature List of individuals involved in this study Name Title Professional Affiliation To be completed by Nebraska Anatomical Board Donor Number Organization from which anatomical material received Material transported by To Room Approved By Date and time tissue TAKEN for study By Authorization for cremation on file Plan for final disposition UNMC Anatomical Board Representative. Anatomical Board of the State of Nebraska 986395 Nebraska Medical Center Omaha Nebraska 68198-6395 Voice 402 559-6249 Fax 402 559-3400 Department of Biomedical Sciences School of Medicine Creighton University Omaha Nebraska 68178 402 280-2015 REQUEST FOR ANATOMICAL MATERIAL Department of Genetics Cell Biology and Anatomy College of Medicine University of Nebraska 402 559-4030 Date Date material needed for study Time material needed for study Bill to Unit Cost Name of person requesting tissue Total Cost Position Telephone number Institute/Professional Affiliation Purpose of study circle Education student resident professional Research Clinical Region involved in this study Number of donors needed for this study Preparation A Embalmed B Lightly embalmed C Non-embalmed IBC protocol number Location of study Name and phone of person responsible for the care and RETURN of tissue Please use back of this form to identify individuals involved in this study. We hereby certify that the human anatomical material taken for this study will be used only for the educational or research purpose stated above at the location indicated on this form* The Anatomical Board reserves the right to inspect the facility where the tissue is located at any time. Although non-embalmed donors will be tested for HIV and Hepatitis B C all human tissue should be treated as potentially hazardous material* We therefore also acknowledge that everyone involved in this study is aware of the potential hazards of working with human tissue and has received all necessary training for its safe handling. We hereby certify that the human anatomical material taken for this study will be used only for the educational or research purpose stated above at the location indicated on this form* The Anatomical Board reserves the right to inspect the facility where the tissue is located at any time. Although non-embalmed donors will be tested for HIV and Hepatitis B C all human tissue should be treated as potentially hazardous material* We therefore also acknowledge that everyone involved in this study is aware of the potential hazards of working with human tissue and has received all necessary training for its safe handling.

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