Basic Information |
Investigator |
| * First Name |
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| * Last Name |
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| * Department |
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| * Email Address |
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| Phone |
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Drop off person/other contact information |
| * First Name |
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| * Last Name |
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| * Department |
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| * Email Address |
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| Phone |
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| * Title of the research |
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| * Is the work request for research purpose? |
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Method of Payment |
| * Type of Funding |
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| Internal (Inside GW): Grant sponsored PTA number |
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| Non grant sponsored funding: Banner ORG/ALIAS number |
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| * Source of funding |
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| Cost center number (if applicable) |
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| *Note: Investigators outside of GW requesting work, please make payment via check to the remittance address
provided. |
| * Person responsible for payment (Full name as Signature) |
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I hereby certify that I have personally filled out this form and the information in complete and accurate. By signing this section
of this work request, I agree to abide by and be subject to the University's rules, regulations, and disciplinary code. I
further understand that it is my responsibility to assure that all documents necessary to complete my work request arrive in a
timely manner.
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| * Signature |
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Work Requested |
| * Type of work requested Check all that apply |
Histology
Frozen sections
EM
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| * Date drop off |
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| * Type of service |
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Specimen Information |
Animal Tissue |
| Animal Type |
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| Tissue Type (lung, kidney, etc.) |
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Human Tissue |
| Tissue Type (lung, kidney, etc.) |
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| Fixative in |
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| Time of Fixative |
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Sample IDs |
Please enter your Sample IDs below (Note: The textbox scrolls and can be expanded if needed):
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Histology |
| Routine Processing |
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| Routine Embedding |
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| Embedding Instructions/Orientation Description |
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| Cutting |
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| Section Thickness (3 microns-routine) If other, please state |
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| Total No. slides per block |
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| If levels or serial sections, please explain |
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| Unstained/block |
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| H&E/block |
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| Special Cutting Instructions |
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Special Staining |
| Special stain ordered |
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| Control block/slides provided |
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| Special Instructions |
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Immunohistochemistry |
| Antibody provided by Investigator |
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| Antibody optimization required |
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| Control block/slides provided |
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| If yes explain the optimization conditions |
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| Additional material provided by Investigator |
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| Special Instructions |
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Frozen Sectioning |
| OCT Embed |
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| Cutting Thickness |
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| How many blocks |
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| How many slides per block |
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| H&E/block |
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| Unstained/block |
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| Special Instructions |
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