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UIC Flow Cytometry Sample Submission Form Name________________________________________ Date___________________ Advisor’s signature (UNH only)____________________________________________ Grant #/ Company/PO#__________________________________________________ Phone #_________________________________ Email________________________ Address (if on campus, what building?) _____________________________________ Sample name_____________________________ Sample composition____________ What exactly do you want to measure? What kind of information are you looking for? Type of sample(s) (e.g. bacteria, cultured endothelial cells, nuclei, etc) and species of origin: _____________________________________________________________________________ Dye(s) used (e.g. PE, APC, FITC):___________________________________________________ Is your sample(s) LESS than 70 microns? ____________________________________________ How many samples are you submitting? ____________________________________________ Is your sample fixed (rendered harmless)? __________________________________________ Is your sample TOXIC? State all biological and chemical hazards associated with your samples. _____________________________________________________________________________ Have you included all the necessary CONTROLS? _____________________________________ Please list your controls: _____________________________________________________________________________ It is most helpful if you get this form to Mark Townley (Rudman 312, [email protected]) a day or two prior to your appointment. Disclaimer: Quoted charges are only approximations based on accepted sample preparation protocols and instrument procedures. Actual charges may vary when additional work is required (on samples) because further preparations are needed/required or because the results/data produced initially may not have been adequate/appropriate/conclusive, even though procedures were properly followed and the instruments were working correctly. Additional work may involve additional charges. If charges exceed the original estimate, work will not proceed unless approved in advance by telephone or e-mail. Copyright 2013 University Instrumentation Center UNH W123 Parsons Hall 23 Academic Way, Durham, NH 03824 Phone: 603-862-2790 Fax: 603-862-4104 www.unh.edu/research/uic Rev A 3/2013
