Request Form

Name: __________________________________________________________________________________________

Institution: ______________________________________________________________________________________

Department: _____________________________________________________________________________________

Shipping Address: ________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

Telephone Number: ___________________________ Fax Number: ____________________________

Internet Address: _____________________________________

Shipping Company _____________________________ Account Number: ________________________

Note: All specimens will be shipped to the above address. Specimens cannot be shipped to a post office box.

Purchase order number or internal billing number (for freight charges), if required by your institution: ________

My institution is (check one): ______ a non-profit organization; or ______ a commercial organization.

My research is supported by (specify type and identification number):

NIH Intramural Research: _________________________________________________________________________

NIH Extramural Funding Award Number ____________________________________________________________

Other Federal Funding ____________________________________________________________________________

State Funding ____________________________________________________________________________________

Private Foundation _______________________________________________________________________________

Funding Outside of the United States ________________________________________________________________

Industry ________________________________________________________________________________________

Other __________________________________________________________________________________________

Certification of Compliance with Safety Standards:                                                                        Initials: __________

I am aware that all specimens distributed by the NHLBI Biologic Specimen Repository may be potentially biohazardous even when they are not specifically designated as such. I understand that the requested specimens may pose health risks to persons handling or in the vicinity of the specimens, the environment, and the community. I certify that I am cognizant of and will employ the appropriate biosafety standards including special practices, equipment, and facilities. I shall comply with all applicable Institution and Government health and safety regulations and the guidelines detailed in: Biosafety in Microbiological and Biomedical Laboratories, 3rd Edition, HHS Publication No. (CDC) 93-8395, May 1993, or the most recent revision of these guidelines. I will directly supervise all users of the specimens and I will assume responsibility for assuring that those users are cognizant of and comply with safety standards and good laboratory practices.

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