NCI-Frederick Receiving and Quarantine - Non-Approved Source

Non-Approved Sources: Request for the Importation of Animals into NCI-Frederick Receiving and Quarantine Facility

Please complete the following form, then press the "Submit Form" button.

1. Animal Study Proposal Number
Animal Study Proposal Number:
Cost Center Number:

2. Requesting Investigator
Investigator:
Investigator Phone #:
Investigator Email:
Lab Contact:
Contact Phone #:
Contact Email:
Lab Contact Building Number:
Contact Street Address:
Contact City:
Contact State:
Contact Zip:
Contact Country:

3. Receiving Facility
NCI-Frederick facility in which animals will ultimately be housed:
	Cryopreservation Rederivation Speed Congenics
Bethesda facility in which animals will be housed:
1^st choice:
2^nd choice (if applicable):

4. Investigator Providing Animals
Investigator:
Email Address:

5. Sending Institution
Sending Institution:
Address:
Building in which animals are currently housed:
	Building:		Room #:

6. Contact for Health Status Report
Name:
Email Address:
Phone #:
Fax #:

7. Contact for Shipment (contact at sending institution)
Name:
Email Address:
Phone #:
Fax #:

8. Information on Animals
Anticipated date of arrival:
Genotype of mice being sent:
Strain of mice being sent:
Characteristics (i.e., coat color):
Number:	Males:
The date of birth is helpful if it is known. To enter a single date, please use the first box only. To enter a date range, please use both boxes.	Date of Birth:		to
	Females:
	Date of Birth:		to
Animals in mating pairs:	Yes No
Animals pregnant or with litters:	Yes No
Do the animals have a functional immune system?	Yes No Unknown
	If unknown, explain:
Special Notes/Instructions:

9. Institutional Biosafety Committee Information
1) Are these animals genetically engineered?		Yes No
Are these animals genetically Modified?		Yes No
2) If so, what is the mechanism? (i.e. transfected, recombinant) :
3) Do the animals contain a virus (either an animal or human virus)?		Yes No
4) If applicable, NCI-Frederick Institutional Biosafety Committee Registration Number:



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