Indiana University Vector Production Facility

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Sample Submission Form - NCRAD
NOTE: Due to HIPAA regulations, please do not use personnel patient information as a sample identifier
THIS FORM MUST BE FILLED OUT AND SUBMITTED PRIOR TO SENDING SAMPLES FOR TESTING! PLEASE READ THE INSTRUCTIONS FOR PREPARING AND SENDING SAMPLES HERE. ONCE THE FORM IS SUBMITTED, SOMEONE WILL CONTACT YOU TO COORDINATE THE SHIPPING OF SAMPLES.
This is the first time I have submitted samples to NCRAD for mycroplasma testing.
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

Additional notes, comments, requests and/or instructions:

Questions/Comments: If you have questions or comments regarding the mycoplasma testing or the sample submission process, please contact Troy Hawkins at (317) 278-1628 or send an email to troyhawk@iupui.edu

NOTE: This testing is paid for by NCRAD only for cell lines being submitted to the repository - assay results are therefore only reported to NCRAD.

For security reasons, please fill in the box above.