Date Submitted:	1/17/2009
Person submitting sample:		E-mail:
Copies of test results should also be provided to:
Investigator:		E-mail:
Program:
Building:		Room:
Phone:		Fax:
Cost Center #:		Yellow Task #:
Received from:		at (location):
Sample designation:

Type of Material
Species of origin:	Mouse Rat Human Other - Please explain:
If hybridoma, fusion between what species:
Mouse/Mouse Mouse/Rat Human/Other    Other - Please explain:
Cell type:
Ascites (type):
Other:
Does it contain virus?
Yes No Unknown
If yes, what virus?
If of human origin has reverse transcripase activity been tested for?
Yes No Unknown If yes, please send a copy of result to the AHDL at fax 301-846-6031 and reference the investigator name and sample designation.
Has this material been genetically manipulated (i.e. transfected, recombinant)?
Yes No Unknown If yes, please indicate:
Mechanism:
NCI IBC #:

Passage History
Passage #:		In what?
Has the material ever been in animals?		Yes No Unknown
If yes, please indicate:
	At what passage?
	In what animals?
Is this material currently being passaged in animals at NCI-Frederick?
	Yes - Please list building: No Unknown
Human pathogen?		Yes No Unknown
If yes, please indicate:
	Name of Pathogen(s):
	NCI IBC #: