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 shipping
Housing Location Type *Housing location
Room# Method of Importation

Mount Sinai Investigator Information

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

Lab Contact
*Lab Contact Name *Phone
* Email

Shipping/Receiving Institution Information

*Domestic or International *PI 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

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. If an MTA is required, is it in process? If No, please contact http://www.otbd.org/formssm/agreements/ to initiate the MTA process.
2)

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