REQUEST FOR TRAINING FORM - EXTERNAL Industry

Date of Request: *

Company or Institution Name: *

First Name: *

Last Name: *

Your Email Address *

Requester Phone Number: *

Type of Request * Module 1 (Room Temperature TEM) Module II Cryo TEM

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.

Why do you want to take this course? Briefly describe long & short term goals. *

Company Mailing Address: *

If accepted I agree to a charge of $6,750/per module for training costs. I understand that I will be charged at the start of the class. Class size is limited to 4 students; therefore, no refunds will be allowed once class has started.

Contact Person for billing:

Contact Phone Number:

Upon completion of training, do you plan on utilizing the UMass Chan Cryo-EM facility: * Yes No

If yes, please provide a summary of your potential work in the Cryo-EM facility:

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

Is recombinant DNA found in this sample? * Yes No

Is this sample derived from any pathogen, or cells or tissues infected with a pathogen? * Yes No

If any of the answers above is yes, what is the risk group: RG1 RG2 RG3

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

Is this sample human tissue? (Including blood or blood products) * Yes No

What biocontainment level is necessary? * BSL-1 BSL-2 BSL-3

If any of the answers above are “Yes,” does Submitting PI have IBC approval? Yes No

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.