Maryland Anatomy Board

Maryland State Anatomy Board

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Submit Offsite/Release Request

Date of Request:

Date of Pick-up:

Person Picking Up:

Date of Return:

Person Returning:

Personal Information

Requester Name:

Requester Email:

Requester Phone:

Requester Address:

Requester City:

Requester ZipCode:

Requester State:

Study Details:

Specimen Prep:
Specimen Type/Cuts:

Number of Specimen:

Any Donor Criteria (Specify):

Organization Information

Organization Name:

Organization Address:

Organization City:

Organization ZipCode:

Administrative Contact Name (if other):

Administrative Contact Email (if other):

Administrative Contact Phone (if other):

Procedures Being Performed (List):

Special Requests (Describe)

Invoice Information

Invoice Contact Name:

Invoice Contact Phone:

Invoice Contact Email:

Invoice Contact Address:

Invoice Contact City:

Invoice Contact State:

Invoice Contact ZipCode:

Invoice Reference:

Invoice Tax Number:

Requester Declaration:

My e-signature below indicates that I agree to the following terms and conditions, and that I am aware I have had the opportunity to ask the SAB questions to clarify any of these terms and conditions;

a) I attest that all participants taking part in this study shall display decorum, respect for donors, and ethical conduct expected of medical professionals, and that I shall ensure disciplinary action is taken for any participant misconduct;

b) I attest that all participants within this study have received training in sharps safety, blood-borne pathogen, safe PPE donning, that my institutional laboratories are EHS/OSHA compliant for housing and handling human tissues and that the SAB shall not be held liable for any accident arising from participant conduct or facility deficits;

c) I understand that this study request is not a guarantee and that the SAB shall do its best to provide the requested donors and donor criteria, and I recognize that the request may not be fulfilled in part or in full due to available SAB resources and SAB policy on study prioritization, and that the SAB shall make a good-faith effort to notify me as soon as possible if there is a likely inability to fulfill my study request

d) I understand that the requested specimens, numbers and dates are tentative and are not scheduled until SAB staff approve my study request and provide schedule confirmation, and that I am responsible for the costs and coordination of all specimen transportation to/from the SAB in accordance with Maryland regulations;

e) I understand that the SAB may refuse service to any individual, group, or institution for failure to comply with ethical handling of donors, professional interactions with staff, or safety procedures;

f) I understand the SAB cancellation policy and agree to pay all study fees as incurred;
- Cancellation more than 5 full business days before the scheduled pick-up date = no fee
- Cancellation between 2 to 5 full business days prior to the pick-up date = 50% study fee
- Cancellation less than 2 full business days prior to the pick-up date = full study fee

g) I understand that the SAB may cancel my study request at any time, for any reason, and that I shall not be billed if the SAB cancels my study request. I understand reasons for cancellation include, but not limited to, inclement weather, facility emergencies, urgent facility maintenance, etc., and that the SAB shall make a good-faith effort to notify me as soon as possible if my study request has been cancelled;

h) I agree to return SAB specimens on date specified in my request, and I shall request an extension in unforeseen circumstances, and I understand that unapproved return delay will incur a late return fee;

i) I understand that the SAB may conduct a site visit and/or audit review with 24 hours advance notice, and that the SAB may order return of all specimens at any time with 24 hours advance notice;

j) I attest that I shall perform no procedures on SAB donors beyond those approved on my request, and I understand that performance of unapproved procedures shall incur additional body use fees and potential refusal of future service;

k) I understand the SAB retains exclusive control over all donors and that loaning, gifting, reselling, retaining, final disposition, or other transfer of an SAB donor or specimen is prohibited without written authorization from the SAB;

l) I understand that the SAB reserves the right to take legal or disciplinary action, at the discretion of the SAB, against an individual, group, or institution for breach of the foregoing conditions, law, or SAB policy.

Submit Offsite/Release Request

Personal Information

Study Details:

Organization Information

Invoice Information

Requester Declaration:

All necessary data must be entered or request will be denied.