Form for embryo transfer

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*Before the embryo transfer service can be performed, recent (within 90 days) health status report on the mouse colony of origin must be obtained from the embryo providing institution and submitted to CCM for an approval whether the recipient mice are subject to quarantine at UVa.*

Date

PTAO*

Funding source

Contact person

Phone

Email Address

Department

UVa Cancer Center member?

Yes No

UVa Diabetes Center member?

Yes No

Mouse line ID*

Primary locus symbol/gene name

Source of frozen embryos

Type of frozen embryos (ctrl-click for more than one choice)

Number of straws (vials)

Number of embryos each straw (vial)

Embryo thaw protocol (must be provided if embryos are not frozen by GTTF)

Yes No

Number of mice which embryos should be transferred to (up to 3 mice per charge)

Number of embryos each mouse should receive (10-20 embryos)

Animal protocol #

CCM #

Room where recipient mice should be placed

Mouse health status report has been submitted to CCM*

Yes No

If not, please contact CCM with the name and location of the shipping institution, name of the donating scientist, name of the institution's veterinarian.

Note to GTTF

PI signature

Please click "Submit" button to send the request electronically to GTTF. Click "Back" button on your web browser to print, sign and bring the form to Jordan 2223 (ext. 2-3990) to confirm the timeline of the service.

University of Virginia Health System