Testing Services Order Form 1. Customer Information 2. Billing Information Principal Investigator Customer ID Project Coordinator Billing Contact Project Name Purchase Order Institution PO/Street Address Building City Street Address State / Prov / Zip City Email Address Phone Number State / Prov / Zip Fax Number Phone Number Email Address Please type bioshipper / sample return address if different from Customer Information Additional report to 3. Collection Method: Passive Drool Oral Swab (SOS) 4. Known Infection Agents? Yes No List: 5. Total Number of Tubes Submitted: Total for Assay #1: Total for Assay #2: Total for Assay #3: Total for Assay #4: Total for Assay #5: Children’s Swab (SCS) Infant Swab (SIS) Other: Post-Testing: Please check as many as applicable Discard Samples (Fee applies, 30 days after testing) Archive Samples (Fee applies) ____________ Return Samples (Cost of shipping applies) ____________ Return Shipping Materials ($25 unless return label supplied) ____________ Grid boxes? Bio-shipper? ____________ Please check if Return Shipping Label is included ____________ 6. Test Menu: *Indicates singlet test, all other tests are duplicate. **Flow-rate correction recommended. **Please indicate total number of each test in #5 above.** -amylase*, ** DHEA-S** Melatonin Androstenedione DNA Extraction (Archival) Multiplex (see below) Adiponectin DNA Extraction (SNP) MMP-8 Blood contamination* EBV-antibody Progesterone CMV-Antibody Estradiol 17-OH Progesterone Cortisol Estriol Secretory IgA** Cotinine Estrone Testosterone CRP** DHEA IL-1β (single plex) Total protein IL-6 (single plex) Uric Acid For Multiplex testing, please Indicate desired cytokines (minimum of 4): GM-CSF IFN-γ IL-1β IL-2 IL-6 IL-8 IL-10 IL-12p70 TNF-α Other: 1 Contact the Center: IISBR@asu.edu | 480.965.6944 Testing Services Order Form 7. Weigh Tubes for flow-rate (charge applies): 8. List tests in order of importance: Yes No 9. IRB Information: The IISBR will need a copy of your IRB/IACUC approval letter on file prior to beginning any work on this project. Do you currently have IRB/IACUC approval for this project from your organization? Yes No Has a copy of your IRB approval been sent to the IISBR? Yes 10. Quote Information: Please provide quoted prices you have received for this study. Analyte: Quoted Price: No Notes to IISBR: ***************************************************Do not write below this line ********************************************* Date Received Sample No. Inventoried By IISBR ID Vial Type Freezer/Shelf E-mail Sent Roster Printed Box Return Date Sample Discard Date Contact the Center: IISBR@asu.edu | 480.965.6944 2