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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:
Project ID:

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:
1st choice:
2nd 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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