Cocaine Biobank V3

Cocaine Biobank Request Form

www.cocainebiobank.org University of California San Diego For questions contact: Lisa Maturin at lmaturin@health.ucsd.edu

Email*

First Name, Last Name*

John Doe

Phone Number*

XXXXXXXXXX

Institution*

Project Description

Project Title*

Project Abstract*

Funding Source*

Select or enter value

Grant Number

Samples Details

Tissue Requested*

Select or enter value

Brain Regions

select only if brain regions were selected

Select or enter value

Other Brain regions or organs

Sex

Select or enter value

Preservation Method

Select or enter value

Timepoint

Select or enter value

Phenotype Criteria

If a specific phenotype is needed, please let us know which one. Representative population, High vs. low with a median split, top/bottom quartile, or specific behavioral features. Example of dependent variables include: responding under fixed ratio, progressive ratio, despite foot shock, time-out responding, composite addiction index, irritability-like behavior.

Experimental design and N*

Please specify N for each sex and each group example: 4 groups Naive: N=12 (6M+6F) Intoxication: N=12 (6M+6F) Or Naive: N= 12 (6M+6F) Intoxication HIGH addiction: N=12 (6M+6F) Intoxication LOW addiction: N=12 (6M+6F)

Total number of rats*

Sum of all the rats needed, including naives (if needed)

Total number of samples*

may be different than number of rats if there are multiple organs per rats

Comments

Additional comments related to your request

Shipping

Note that the receiving institution will be responsible for all cost related to shipping and handling of the samples. You will need to provide a Fedex or alternate shipper account number.

Shipping Address*

Fedex Account number

MTA

In order to send samples out to you, we must have a Material Transfer Agreement in place. Please provide the following recipient information.

Name of PI requesting samples

email of PI requesting samples

Phone number of PI requesting samples

Name of Signing Official

Email of signing official

Phone Number of signing officials

Send me a copy of my responses

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