NCI-Frederick Receiving and Quarantine - Modified-Approved Source

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

Please complete the following form with as much detail as possible. The information submitted on this form is used to arrange the shipment of your animals into the Receiving and Quarantine facility. If there are any fields that are not applicable to your shipment request, please type "NA" into the provided space. Please keep in mind that email addresses are required in the appropriate format and "NA" will not be accepted in these fields. Upon completion, please press the "Submit Form" button. A copy of the request will be sent by email to the Receiving and Quarantine staff and you will receive an electronic receipt by email. Please click here for an overview of quarantine testing requirements and expected release dates. If you have any questions regarding the completion of this form or your animal shipment, please contact the Receiving and Quarantine office at 301-846-1133.

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 IVF
Bethesda facility in which animals will be housed:
1^st choice:
2^nd choice (if applicable):

4. Sending Institution
Sending Institution:
Room in which animals are currently housed:

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

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

7. 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:

8. 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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