Hong Kong Baptist University
School of Chinese Medicine
Research and Development Division
Job No.:
MS-
-
Request Form for Mass Spectrometry Service
Name:
Supervisor:
Date:
Tel:
E-mail:
Sample code: (alphanumeric only)
Room No.:
Sample returned
 YES  NO
Univ. / Dept.:
 BU / SCM
 BU /
 Others
Project Type:
 UGC
 BU (FRG)
 Undergraduate
to
 Postgraduate
 Non-UGC (Please specify)
Project No.:
A/C No.:
Proposed maximum service charge for this analysis:
HK$
A. Chemical Information:
No. of Analyte:
Use separate sheet or RDD-FormMS2 to provide further information.
Analyte Name:
Structure (Draw below or refer to attachment)
Empirical Formula:
Molecular weight
(mono-isotopic):
Molecular weight
range:
Solvent (in which
solvent dissolve):
Concentration
(mg/mL):
Purity:
B. Hazards: (THIS SECTION MUST BE COMPLETED)
 Corrosive
 Explosive
 Harmful
 Irritating
 Carcinogen  Mutagen
 Pathogenic (for Human clinical samples)
 Other (please specify):
 Toxic
Signature of Applicant:
MSDS of the above chemical(s) should be provided upon request.
C. MS Techniques Required (please check as required)
 Qualitative / Identification
 Quantitative / Target Analysis
 ESI
 Positive ion Mode
 Negative ion Mode
 APCI
 Positive ion Mode
 Negative ion Mode
 Concurrent ESI & APCI
 Positive ion Mode
 Negative ion Mode
 MS1  MS2
 LC/MS (please attach experimental details)
 Microfluidic ESI (LC-Chip based)*
 Mass spectral fingerprinting*
Mass Accuracy (for high resolution MS only)
 5 -20 ppm  < 5 ppm
* Techniques only available after discussion with technical staff.
(RDD-Form MS1: Sep 2013)
Page 1 / 3
Hong Kong Baptist University
School of Chinese Medicine
Research and Development Division
Job No.:
MS-
-
Request Form for Mass Spectrometry Service
D. Sample Information: (Please specify the no. of sample(s))
No. of samples:
 Reference standard
 Biological sample (animal)
 Herbal extract
 Biological sample (human)
 QC sample
 Others
TOTAL NO OF SAMPLES:
Brief description of MS service requested. (Please provide details such as sample nature, sample preparation,
solvents, special requirement and cited reference for reference.)
Remarks:
1. Service will not be carried out if insufficient information was provided.
2. Sample information and analysis sequence MUST be entered properly in the pre-defined Excel template
(RDD-FormMS2.xls and RDD-FormMS3.xls) and submitted via E-mail to rddms@hkbu.edu.hk together
with this request form. Submit this form to MS Service in-box at SCM707.
3. Applicant will be responsible for extra expenditures on special non-routine chemicals (e.g. unusual solvents /
reagents, consumable items, column, LC-chip, testing kits) and reference chemical marker(s).
4. All sample(s) and reference standard(s) must be labeled properly.
E. Acknowledgement:
1. A suitable acknowledgment of the funding MUST be included in any publication/publicity arising from the
work done by this mass spectrometry service.
2. If you are using Agilent 6460 Triple Quadrupole Mass Spectrometer for your work, you should quote the
acknowledgment as:
“The major equipment used in this paper was substantially supported by the Special Equipment Grant from
the University Grants Committee of the Hong Kong Special Administrative Region, China (SEG_HKBU03)
and Hong Kong Baptist University” or “本項目內使用的主要儀器由香港特別行政區大學教育資助委員
會特別儀器資助金及香港浸會大學撥款資助 (SEG_HKBU03)”.
3. If you are using Agilent 6540 Quadrupole Time-of-Flight Mass Spectrometer for your work, you should quote
the acknowledgment as:
“The major equipment used in this paper was substantially supported by research grant from The Baptist
Chinese Medicine Research Centre Limited (BCMRC/08-09/01-RDD) and Hong Kong Baptist University” or
“本項目內使用的主要儀器由浸會中醫藥研究所有限公司資助金及香港浸會大學撥款資助
(BCMRC/08-09/01-RDD)”.
Signature of Applicant:
Signature of Supervisor:
RDD MS Service Staff Use Only:
Instrument:
Technique:
Operator:
Date:
(RDD-Form MS1: Sep 2013)
Filename:
Page 2 / 3
Hong Kong Baptist University
School of Chinese Medicine
Research and Development Division
Job No.:
MS-
Request Form for Mass Spectrometry Service
F. To Be Completed by RDD:
Service:
 accept
 reject
Reason for rejection:
Accepted by:
Approved by:
Name and signature
Name and signature
Date:
Date:
G. Workflow and Charge:
Date Start:
Item
Total Equipment Time:
No. of Total Samples:
Additional Charge:
Total Charge:
Debit Note / Invoice Date:
Date Completed:
Quality
Hr(s) HK$
Unit Rate
per hour
HK$
Debit Note / Invoice No.:
Payment Received:
Remarks:
Handled by:
(RDD-Form MS1: Sep 2013)
per sample
Date:
Page 3 / 3
Sub-total
HK$
HK$
HK$
HK$
-