PRR Project Request Form
Contact Information
1. Request date:2. Requested by: / E-mail address:
3. Principal Investigator:
a. P.I name: / Title:
b. Department:
c. Mailing Address:
d. E-mail address:
e. Office Phone Number:
f. Funding source/Chartfield: / *Please submit a WAF with an active Chartfield.
4. Cancer type of interest: 1. Breast 2. Colon 3. Sarcoma 4. Other
If you check #4, please indicate:
Project Request
1. Project
a. Title of the project:
b. Please provide a project description, including scientific merit statement, in one short paragraph (4-5 sentences).
2. IACUC protocol
a. This project will be under the 1. PRR IACUC protocol (*amending process takes 2 – 3 weeks)
or 2. IACUC#: , PI name:
b. If you have checked 2:
Is PRR staff(s) in the protocol? 1. Yes 2. No (if No, please add the staff(s) in your protocol)
3. Mouse
a. Mouse Strain: / Source (if preferred):b. Age:
c. Sex: Male Female
d. Room: HCI Rm LL125 Other room (please specify) :
e. USDA pain level:
4. Mouse Food (please specify if you have preferences)
5. Tumor(s)
a. Which tumor(s) do you want to use? :
b. Can you provide cells for engraftment? Yes No
c. If no, please indicate contact information of the provider or merchant of the cells.
d. Details on injection (i.e. site of injection, # cells to inject, with or without matrigel, approximate growth time if known, etc.)
e. Will tumor measurement be done by calipers or luciferase (or other) imaging and how often?
6. Drug(s) and delivery method(s). If you have more than one, please indicate each below in the same format.
Drug 1
a. Drug (Please provide us the agent.):
b. Vehicle:
c. Storage method (and duration):
d. Please describe instructions for preparation of the agent(s):
e. Drug treatment starts when:
f. Route (i.e. IP, oral etc.):
g. Dosage (mg/kg):
h. Frequency:
i. Total duration and end date:
j. Is there any indication that your drug might be toxic or hazardous to humans?
Yes No
Reference:
k. Has the drug or vehicle been used in animals previously? If so, provide details, results, and reference, if possible:
7. Please draw a diagram of experimental arms, including number of animals per arm. Include any other details important for the experiment.
8. Numbers of mice needed for the experiment. Please provide a statistical power analysis (using data from previous experiments) or literature reference (of similar experiments or similar drug) that supports using the number of animals per group.
9. Euthanasia
a. Euthanasia method (agent, dose etc.):
b. We are not allowed to use death as an endpoint. Please indicate other signs of sickness or discomfort that would serve as a surrogate for toxicity and be criteria for euthanasia.
10. Do you need necropsy or tissue at the endpoint(s) of the study? Yes No
If yes, which sample(s) do you want to collect? Please provide details for collection.
a. Serum
· Which serum tube? :
b. Tumor:
i. Flash frozen: mg
ii. Fixed tissue:
1. Which fixative? :
iii. Other method (please specify):
c. Other sample(s), collection method(s):
11. Please provide any other information that is relevant to this study.
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PRR Project Request Form updated June 2014