registration form

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UQBR
Registration Request Form – Embryo Thaw and Rederivation
Date:
____________________________________________________________________________________
Contact Details
Chief Investigator
Name:
Email Address:
Department/Institute:
Contact Researcher/Alternative Contact
Name:
Email Address:
Department/Institute:
Fax:
Contact Phone:
Contact Phone:
After Hours Phone Contact:
Billing/Mailing Address:
Dept/Building/Street Address:
____________________________________________________________________________________
Animal Ethics Approval Details (Please attach a copy of the AEC Approval Certificate)
AEC Approval No.:
Expiry Date:
Project Title:
IBC/OGTR No:
Dealing Type (eg DNIR, NLRD):
____________________________________________________________________________________
Service Required: Embryo Thaw and Rederivation of mouse lines
Mice Details
Number of strains: ........................................................................................................................
Name of strain/s: ..........................................................................................................................
Number of straws/vials available: ...............................................................................................
Storage site if not TASQ: ……………………….....................................................................................
Screening requirements:
All progeny from rederivation will be tissue sampled for genotyping.
This will ensure that all mice born from the rederivation are of the correct genotype required by the
Client.
Samples to be:
 Collected at AIBN stores
 Shipped to client. Shipping Address for samples: ……………………………………………………………….
……………………………………………………………………………………….…………………………………………………………
 Sent to genotyping service. Name and contact for genotyping company: ………………………….
………………………………………………………………………………………………………………………………………………….
Strain Description
Name of strain (ie short name, what do you call it):
Official Nomenclature of Strain Name (Please use information from the IMSR
(http://www.findmice.org/index.jsp) or MGI (http://www.informatics.jax.org/) websites if possible and
include MGI Accession # if relevant):
Other Pseudonyms:
If obtained from a commercial institution (eg JAX) please provide Stock No.:
Date Acquired:
Type of Genetic Modification:
Transgenic Knock out Knock in Knock down
Conditional (Flox, ER, Frt) Gene-trap
Other………………………….................................……
What background is the line?
C57BL/6 CD1/ Outbred B6CBF1 (hybrid) 129Sv
Other……………………...........................................………
How many generations has this line been backcrossed? N…
What breeding protocol is required for this line?
Hom x Hom Het x Het Het x Wt
Other...........................................................................
Are there any abnormal behavioural or physiological phenotypes in the line (eg is this line embryo
lethal?)? Yes No
If yes, please describe the phenotype (including time of onset).
Is animal health, welfare, breeding or lifespan affected in other ways? Yes No
If yes, please give details:
What method of genotyping is recommended (eg standard PCR, no screening required)?
Gender of animals to be genotyped: Male Female Either
Please list specific references (eg Source Colony, Publishings):
Gene/Allele Details (If there is more than 1 gene of interest, please attach further details. Please use
information from the MGI (http://www.informatics.jax.org/) website if possible):
Gene Symbol:
Gene Name:
Allele Symbol:
Allele Name:
Genetic modification (Briefly describe genetic modification):
Affected organs/tissues (eg gene expressed in liver only):
Please attach an abstract of the project.
DECLARATION OF UNDERSTANDING AND COMPLIANCE
I, the undersigned:

Have read and understood the terms and conditions of TASQ's Services below and will abide by
these stipulations.

Understand that the service cannot be commenced until this form is returned to TASQ.

Have obtained an Animal Ethics approval and quoted this number and expiry date.

Have obtained OGTR approval and quoted this number.

Understand that TASQ charges apply for each round of thaw/rederive. More than one round may
be necessary for successful rederivation. TASQ cannot guarantee that 100% of embryo transfers
will result in live births.

Understand that courier costs are the responsibility of the client.

Understand that agistment charges will apply once the resulting progeny are weaned.

Understand that a Colony Management levy may apply to those rederived lines needing expanding
prior to shipment.

Have checked/read the TASQ website at http://tasq.uq.edu.au and agree to the charges listed for
this service.
Signature of investigator: ................................................................ Date: .............................
Signature of TASQ Director: ............................................................. Date: .............................
AIBN Building 75, University of Queensland, St Lucia, QLD 4072, Australia
Tel: +61 7 3346 3468 Fax: +61 7 3346 3898
email: [email protected]
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