REQUEST FOR TRAINING FORM

Date of Request: *

Company or Institution Name: *

First Name: *

Last Name: *

Requester 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. *

Mailing Address: *

Check if billing address is the same as your mailing address

Billing Address:

If accepted I agree to a charge of $3250/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 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.

REQUEST FOR TRAINING FORM - Outside Academic