Please complete the following CCMS Animal Shipping Form. The items marked with asterisk (*) are required. We will respond to your inquiry within 2 business days.


General Information

*Shipping Type *Indicate who will be paying for courier fees (CCMS fees to be charged to Mt. Sinai PI only)
*Short-term Acute Use Room#
Method of Importation
Mount Sinai Investigator Information

*PI Name *GCO#
*Protocol# *Fund#
*Phone * Email

Lab Contact
*Lab Contact Name
*Phone * Email
Shipping/Receiving Institution Information

*Domestic or International *PI Name
Collaborator Name *Phone
* Email *Institute
*Street *City
*State (If Domestic) *Zip
*Country


Lab Contact
*Lab Contact Name
*Phone * Email

Shipping Coordinator Information
*Name
*Phone * Email

Veterinarian Information
Name
Phone Fax
Email
Requested Animal General Information

*Animal Type *Available Form
Genetically Modified
Animal Description

*Nomenclature/Line *Background Strain
*Sex * Quantity
* DOB
Genotype
*Coat Color Additional Animals?

Animal Description 2

*Nomenclature/Line *Background Strain
*Sex * Quantity
* DOB
Genotype
*Coat Color Additional Animals?

Animal Description 3

*Nomenclature/Line *Background Strain
*Sex * Quantity
* DOB
Genotype
*Coat Color Additional Animals?

Animal Description 4

*Nomenclature/Line *Background Strain
*Sex * Quantity
* DOB
Genotype
*Coat Color



Additional animal description -
Genetically Modified Animals Questionnaire

Gene 1 Modified Genetic Alteration
Gene 2 Modified Genetic Alteration
Gene 3 Modified Genetic Alteration
Gene 4 Modified Genetic Alteration
Gene 5 Modified Genetic Alteration

Pain and Distress
For each line genetically modified animal to be imported, please indicate the health status of heterozygotes and homozygotes. (Include life span and expected health problems)
Line
Gene Dose Life Span
Health Problems Phenotype

Line
Gene Dose Life Span
Health Problems Phenotype

Line
Gene Dose Life Span
Health Problems Phenotype

Line
Gene Dose Life Span
Health Problems Phenotype
MTA

1. Is an MTA necessary to proceed with this transfer? (If you are unsure, please contact the exporting institutional tech transfer office (or equivalent) to confirm).
1)

2. To submit a request for an MTA, CDA, SRA, or collaboration agreement, go to: https://msip.inteum.com/msip/agreementportal
2)
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