JRF Ortho Surgical Skills Allograft Request Application

General Instructions

Allograft Surgical Skills Objectives

JRF Ortho provides allografts for wet labs and trainings to support the advancement of allograft science, tissue transplantation and other JRF Ortho-related objectives. Various members of the JRF Ortho Research Committee may evaluate applications under an agreement of confidentiality.

Deadline for Application

Please submit at least 1 week before tissue is needed to allow time for application review and distribution of tissue.

Inquiries

All inquiries regarding the application process, administrative requests, etc., should be directed to Mackenzie Smith.

JRF Ortho
7245 S. Havana St., Suite #300
Centennial, CO 80112

Attn: Mackenzie Smith
Clinical and Research Affairs Coordinator
msmith@jrfortho.org

For JRF Ortho Research Allograft requests, please email Msmith@JRFOrtho.org.

Surgical Skills Tissue Application

Allograft Requested

Items marked with an asterisk (*) are specialty grafts, and there is a potential for an extended wait time for availability.

Type	Quantity

Date of Application

Date of Lab

Intended Use

Surgical Technique Practice

Surgeon Training

Wet Lab

Demonstration

Specific Information

Please elaborate with specific information pertaining to the lab/training:

Contact Information

Contact

Name

Phone

Email

Co-Sponsor

Co-Sponsor Name

Co-Sponsor Phone

Co-Sponsor Email

Shipping Information:

Address

Address 2

City

State

Zip Code

FedEx Account Number

FACILITIES (Training location, hospital space, laboratory)

Terms and Conditions

The human tissue provided is intended for surgical skills training purposes only and is not suitable, nor provided, for use in transplantation and research. By signing and submitting a JRF Ortho Surgical Skills Allograft Request, the applicant (including the institution/business organization and training sponsor) agrees to the following Terms and Conditions:

I agree to use the tissue for surgical skills training purposes only. Furthermore, I agree not to transfer the tissue to any third party without prior consent from JRF Ortho.

I recognize that the handling of the tissue may represent a potential health hazard for me and my staff, and I agree to be responsible for all safety precautions which are appropriate for the safe handling and disposal of the tissue.

Applicant is responsible for shipping expenses related to all tissue requests. Shipping must be billed directly to an applicant's shipping account unless otherwise approved by JRF Ortho.

I assume all legal responsibilities arising out of or related to the use, handling and disposal of the tissue for the training purposes. Furthermore, I agree to indemnify, defend and hold JRF Ortho harmless from and against any and all liability, damages, loss or expense (including reasonable fees of attorneys and other professionals) arising from any claim, demand, action or proceedings based, arising out of or related to the use or handling of the tissue by me or any employees of the laboratory or facility at which the training will be conducted.

By executing this signature page, the institution/organization, on his/her own behalf and on behalf of all other sponsors, agree to the provisions of the General Instructions, Terms and Conditions and Specific Instructions of the JRF Ortho Surgical Skills Allograft Request Application.