Microct Service Request Form For External Users Page 2
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2MicroCT Service Request Form for External Users
University of Massachusetts Medical School
Musculoskeletal Imaging Core - µCT LAB
55 Lake Avenue North, S4-326
Worcester, MA 01655
(508) 856-4947
Investigator Name: _____________________________
Phone: ______________________
Contact Name: ________________________________
Phone: ______________________
Institution name: _______________________________________________________________________________
Billing address: _______________________
Specimen shipping address:
_________________________
_______________________
_________________________
_______________________
_________________________
_______________________
_________________________
Payment Method: ________________________________________________
Specify applicable grant number(s), title, agency, and P.I. (for annual review database):
_____________________________________________________________________________________________
_____________________________________________________________________________________________
__________________________________________________________________
Sample Submission Date: ____________________
Investigator Study
Reference Number: ___________________
Sacrifice/storage date: __________________
Storage media: _______________________
Species (circle one):
mouse
other
list mouse strain: _____________________
Total number of specimens:
Bone Type: (e.g., limb, vertebrae, joints)_________________
(Number of Eppendorf tubes/vials)
Gender: M
F
Age:
wks
mos
ATTACH COMPLETED SAMPLE INVENTORY LIST
Animal Background (Transgene or Gene Ablation, Phenotype):
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Treatment Procedure/Agent (drugs) & Duration of treatment:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Dynamic (fluorescent) labels? (circle one):
Yes
No
Agent, delivery, and # days between injections:
_____________________________________________________________________________________________
Purpose and Details of µCT study, Special Instructions:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Internal Use:
Scan Complete Date: _________________
Analysis Complete Date: ___________________
Data Return Date: ___________________
Specimen Return Date: _____________________
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