Indiana University Vector Production Facility

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Resource Program National Gene Vector Bio Repository

Sample Submission Form - Certification Testing Services (Research Grade)
NOTE: Due to HIPAA regulations, please do not use personnel patient information as a sample identifier
PO / Invoice #*:
PI/Sponsor Name*:
Address 1*:
Address 2:
Phone #*:
E-Mail*:

Sample Submissions Information: (If more than 5 samples are to be submitted, fill out separate forms as needed)
Sample #	Your Sample ID(s):	Description(s): Include quantity, concentration, type of cell line, etc
1*
2
3
4
5

				Sample #
Testing Services/Options:		Available for cells, Sup or Both:	Amount required for Test	1	2	3	4	5
A.	Direct S+L - RCR	Supernate	5mLs
B.	Extended S+L - RCR	Both	Up to 5x10⁶ cells or 20 mLs sup
C.	Extended S+L - RCR (up to 5x10⁶ cells or 20mls Sup)	Both	6x10⁶-5x10⁷ cells or 21-100 mLs sup
D.	Extended S+L - RCR (up to 1x10⁸ cells or 0.5 1L Sup.)	Both	1x10⁸ cells or 0.5-1L sup
E.	Ecotropic RCR (tranasformation foci)	Both	up to 1x10⁷ cells or 20 mLs sup
F.	Sterility	Supernate	5-40 mLs sup
G.	ADA isoenzyme species determination	Cells	3x10⁶ cells
H.	In Vitro Virus² (hemagglutination/CPE)	Both	3x10⁷ cells or 27 mLs sup
I.	Endotoxin³	Supernate	2 mLs
J.	TaqMan-PCR¹ Sample 1* Sample 2* Sample 3* Sample 4* Sample 5*	Both	1x10⁶ cells or 2 mLs sup
K.	Mycoplasma PCR⁴	Both	1x10⁵ cells or 2 mLs sup
L.	RCL² (lentivector safety test)	Both	5x10⁶-1x10⁸ cells or up to 100 mLs sup
M.	p24 titer for HIV-1 based vectors⁵	Supernate	0.5 mLs sup

Additional notes, comments, requests and/or instructions:
Indicate desired target below or in sample description

Other Services: For information on services not listed above, or if you have questions/comments, please contact Troy Hawkins at (317) 278-1628 or send an e-mail to troyhawk@iupui.edu

NOTE: Pricing may change for special requests and/or different quantities. Please also include a printed copy of this form with your samples.

For security reasons, please fill in the box above.