Request for Irradiation by Tufts CMS

Please use the following form to request irradiation of rodents or cell lines by CMS. Please provide at least 2-3 weeks to schedule irradiation. CMS will make efforts to accommodate the requested irradiation date below, but irradiation on that date is not guaranteed. Fees are associated with use of the irradiator. Please contact TuftsCMS-irradiation@elist.tufts.edu for more information regarding fees and for dose rate decay chart.

What will be irradiated?*

animal (e.g., live animal, in vivo)cell line, tissue, etc. (in vitro)

Contact and Billing Information

PI Name*

PI Email*

Name of person completing this form*

Email of person completing this form*

Direct (cell) phone number to contact for emergencies during procedure*

Billing Account #*

IACUC Protocol

IACUC Protocol #*

Irradiation Details

Requested date of irradiation*

Date

Number of doses of irradiation for each animal to receive*

1Other

Number of doses of irradiation for each sample to receive*

1Other

If more than 1 dose, how much time between each dose?*

time between doses

Radiation dose (per dose, in Rads)*

in Rads

Irradiation time (per dose, in seconds)*

in seconds. Use dose decay chart (obtain from TuftsCMS-irradiation@elist.tufts.edu)

Animal Details

Species to be irradiated*

mouseOther

Number of animals to be irradiated*

# of animals

Location of animals prior to irradiation*

Room and rack #'s.

Cage card numbers of cages housing animals to be irradiated (separate by commas or returns)*

cage card #"s

Individual Animal Identification. If you need to differentiate animals from different cages, we strongly recommend you identify individual animals. Provide information on how animals are identified.

animal identification

Sample Details

Sample to be irradiated*

Number of samples to be irradiated*

Sample ID's

Investigator Responsibilities

Please CHECK BOX to confirm and acknowledge investigator responsibilities*

The lab confirms they have arranged with TuftsCMS-husbandry@elist.tufts.edu for sterile caging and medicated diet for this irradiation request.

Please CHECK BOX to confirm and acknowledge investigator responsibilities*

The lab confirms they have arranged with TuftsCMS-drugsandsupplies@tufts.edu for gel food, gel water, and any drugs needed for this irradiation request.

Please CHECK BOX to confirm and acknowledge investigator responsibilities*

The lab confirms that all details provided above are correct, are approved by the Tufts IACUC in an active IACUC protocol, and that the Principal Investigator is responsible for any potential compliance issues that result from inaccurate information provided above.

Notes to our staff:

When you have completed the form, hit the "Submit" button below. You will receive a notification of receipt of your form by email within a few minutes. If you do not, please contact TuftsCMS-irradiation@elist.tufts.edu to ensure that the submission was received.