2570 MSRB II, SPC 5674
1150 W. Medical Center Drive
Ann Arbor, MI 48109-5674
Voice: (734) 647-2910
FAX: (734) 936-2622
http://www.med.umich.edu/tamc/
The University of Michigan
Transgenic Animal Model Core
Sally A. Camper, Ph.D.
Linda C. Samuelson, Ph.D.
Thomas L. Saunders, Ph.D.
Internal Use Only
Date Received
Log Number
Logged By
Date of Request for Transgenic Mouse Production
The genetic background of your transgenic mice will be (C57BL/6 X SJL)F2 . If you desire a different genetic
background you must check the box below.
Check Here for Special Request (Custom Genetic Background or Embryonic Analysis):
Contact Person
____________________
Preferred Method of Contact:
FAX Number:
Phone Number
email address:
ShortCode Number
for Core Recharge
Billing Department
Shortcode Number
for ULAM per diem ____________________
UCUCA
Approval Number
Construct Name
____________________
DNA Concentration:
Transgene Size
P.I. Name _________________________
Preferred Method of Contact:
FAX Number:
ULAM Animal Room
Vector Size
Authorized Signature
email address:
Grant Title
Please explain any reason why expression of your transgene might be lethal in mouse eggs:
Questions required by the University of Michigan Institutional Biosafety Committee:
1. Will your genetically modified animals be susceptible to infectious agents to which they would normally be resistant?
No
Yes
2. Will you use Risk Group 2 agents in conjunction with your genetically modified animals?
Reference: http://www4.od.nih.gov/oba/rac/guidelines_02/APPENDIX_B.htm
No
Yes