CCM Pathology Request System v2.0

Lisa Dillard-Telm, Histologist
Transgenic Pathology Laboratory
C/O Robert D. Cardiff, M.D.,Ph.D.
Professor of Pathology
U.C.D. Center for Comparative Medicine
County Road 98 and Hutchison Drive
University of California, Davis
Davis, CA 95616
Phone: (530)752-2726
FAX: (530)752-7914
rdcardiff@ucdavis.edu

** Items are Required



_____________________ ________________ ________________ ________________ 
Principal Investigator **
 
Institution **
 
Tissue Submitted By **
 
Date in (mm/dd/yy) **
 

Animal Number **
 
Strain **        if other, please specify
 
Experimental      if other, please specify
_______________ [ ]  FVB      [ ]  129
[ ]  C57b6   [ ]  CD1
[ ]  Hybrid
[ ]  Other:     _______________ 		[ ]  Knock-out   [ ]  Transgenic
[ ]  Cre-lox        [ ]  TeT
[ ]  Wild Type
[ ]  Other:           _______________

________________________    _______________________    _______________________ 
Control
 
Carcinogen
 
Virus
 

Promoter 1 **     if other, please specify
 
Gene 1 **
 
Genotype 1
[ ]  MMTV-LTR   [ ]  WAP  
[ ]  C(3)1                [ ]  MT  
[ ]  Endogenous     [ ]  None  
[ ]  Other:         _______________ 		_____________________ [ ]  +/+   [ ]  +/-  
[ ]  -/-     [ ]  +n/a  
[ ]  Unknown   
Promoter 2     if other, please specify
 
Gene 2
 
Genotype 2
[ ]  MMTV-LTR   [ ]  WAP  
[ ]  C(3)1                [ ]  MT  
[ ]  Endogenous     [ ]  None  
[ ]  Other:         _______________ 		_____________________ [ ]  +/+   [ ]  +/-  
[ ]  -/-     [ ]  +n/a  
[ ]  Unknown   
Promoter 3     if other, please specify
 
Gene 3
 
Genotype 3
[ ]  MMTV-LTR   [ ]  WAP  
[ ]  C(3)1                [ ]  MT  
[ ]  Endogenous     [ ]  None  
[ ]  Other:         _______________ 		_____________________ [ ]  +/+   [ ]  +/-  
[ ]  -/-     [ ]  +n/a  
[ ]  Unknown  



[ ]  female
[ ]  male 		_________ _____________ ________________ _________ _________ 
Gender
 
Pregnancies
 
Days of Gestation/
Lactation
 
Date Tumor First Noted 
(mm/dd/yy)
 
Date of Birth 
(mm/dd/yy)
 
Date of Sacrifice 
(mm/dd/yy)
 

Fixative            if other, please specify
 
Post-Fix         if other, please specify
 
Days of Fixation
[ ]  Formalin
[ ]  Paraformaldehyde
[ ]  Gluteraldehyde  
[ ]  Omnifix  
[ ]  Alcohol  
[ ]  Bouin's  
[ ]  Other:    ________________ 		[ ]  Alcohol  
[ ]  Buffer  
[ ]  Other:    _______________ 		_________________

Processing (Routine) [ ]  Yes   [ ]  No
ASAP (Extra Charge) [ ]  Yes   [ ]  No
Tissue Collected [ ]  Yes   [ ]  No
Tissue Fixed [ ]  Yes   [ ]  No
Tissue Frozen [ ]  Yes   [ ]  No

Experimental Protocol/Gross Description:  __________________________________
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