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REQUEST FOR TRAINING FORM - Outside Academic

Core Electron Microscopy Facility
Department of Cell and Developmental Biology
UMass Chan Medical School
55 Lake Avenue North
Worcester, MA 01655\Phone: (508) 856-2602

REQUEST FOR TRAINING FORM - Outside Academic

Type of Request- *

PLEASE NOTE: Module I training is required for Module II unless applicant has substantial previous EM experience and is pre-approved by the staff to be eligible for Module II.

Upon completion of training, do you plan on utilizing the UMass Chan Cryo-EM facility: *

Biosafety (must be completed regarding future work in the facility)

Is recombinant DNA found in this sample? *
Is this sample derived from any pathogen, or cells or tissues infected with a pathogen? *
If any of the answers above is yes, what is the risk group:

See ABSA: http://www.absa.org/riskgroups/index.html

Is this sample human tissue? (Including blood or blood products) *
What biocontainment level is necessary? *
If any of the answers above are “Yes”. Does Submitting PI have IBC approval?

Instructions To Submit a Copy of Your Institutional IBC Approval

Please e-mail a copy of your institutional IBC approval, if applicable, letter to:
(should indicate the biocontainment requirements)

Gregory.Hendricks@ umassmed.edu

For human tissues or pathogens coming from outside UMass Chan, we require that the samples be fixed before shipping to the lab to inactivate any pathogens.