Application for Collaboration and Service Project

Application for Collaboration and Service Project

National Flow Cytometry Resource (NFCR)

Advanced Instrumentation Group (B-9)

Bioscience Division

Los Alamos National Laboratory

The following information is requested to help us better anticipate and evaluate your needs and for NIH reporting purposes. All information will be maintained as confidential.

In order to ensure compliance with NIH regulations pertaining to studies involving Human Subjects and Vertebrate Animals, there are several questions must be answered. If either Human Subjects or Vertebrae Animals are involved in the proposed research at the NFCR, it will be necessary to provide documentation of approvals of IRB for Human Subjects studies and of IACUC for Vertebrate Animal studies prior to initiation of experiments at the NFCR.

Investigators using the National Resource Facility are required to provide a progress report annually. All presentations at meetings or publications need to be reviewed by the NFCR contact person prior to submittal. All meeting abstracts, presentations and publications containing data derived from the Resource are required to acknowledge the NFCR as follows:

"This work was supported by ______and the Los Alamos National Flow Cytometry Resource funded by the Division of Research Resources of NIH (Grant P41-RR01315)."

Date______

1.  Name ______

2.  Address ______

3.  Telephone number ______

4.  FAX number ______

2. Title of proposed project:

______

3. Will Human Subjects be involved in experiments? No: _____Yes: _____

If yes, provide Exemption number: ______or

IRB Approval Date: ______

Assurance of compliance #.______

Will Vertebrate Animals be used in experiments ? No: _____Yes: _____

If Yes, provide IACUC approval date:______and

Animal welfare assurance #.______

4. Name and address(es) of collaborators (outside of Los Alamos) who will be involved in the project:

5. Name of Los Alamos investigators whom you have contacted and/or whom you believe will be involved in the project:

6. Please attach a brief curriculum vitae of the principle investigator using a standard NIH biographical sketch form.

7. List your specific aims and goals in the use of the NFCR.

8. What is the rationale for using the unique capabilities available at the NFCR versus a commercially available instrument?

9. Significance of project (1/2 page maximum; please attach a separate sheet).

10. Specific research plan (1/2 page maximum; please attach a separate sheet).

11. What preliminary work has been done on this project? (1/2 page maximum; please attach a separate sheet).

Contact:

James P. Freyer, Ph.D.

Director, National Flow Cytometry Resource

Bioscience Division

Los Alamos National Laboratory

Mail Stop E535

Los Alamos, NM 87545

505-667-8229 (office)

505-665-4637 (fax)

REV: 08/09/06