service form - usm · 2017. 6. 5. · department/ unit section a: application's detail matrix/...
TRANSCRIPT
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SEKSYEN PENYELIDIKAN HAIWAN INSTITUT PERUBATAN DAN PERGIGIAN TERMAJU
SERVICE FORM
Application no: _______________
Application date: _______________
SERVICE FORM This form has 4 pages including 4 sections. Please check the term and condition on page 2 and fill the form completely. Animal that use for project must be acquired approval from USM Animal Ethics Committee.
NAME
DEPARTMENT/ UNIT
SECTION A: APPLICATION'S DETAIL
MATRIX/ STAFF NO
EMAIL ADDRESS
HP / TEL. NO
SUPERVISOR
DEPARTMENT/ UNIT
PROJECTPURPOSE OF RESEARCH: DIAGNOSTIC TRAINING WORKSHOP
OTHERS*
*PLEASE STATE
PROJECT REF. NO AECUSM REF. NO.
SECTION B: SERVICE PROVIDED
PLEASE TICK (X) FOR SERVICE NEEDED.
HAEMATOLOGY
ANIMAL WORK EXTRACTION TRAINING OTHERS
PROJECT TITLE
Page 1 of 4
IPPT/SPH/FORM-01
*DIAGNOSTIC
HISTOLOGYBIOCHEMISTRY
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SEKSYEN PENYELIDIKAN HAIWAN BAHAGIAN PENYELIDIKAN, PENERBITAN, DAN INOVASI
INSTITUT PERUBATAN DAN PERGIGIAN TERMAJU
SERVICE FORM
Application no.: _______________
Application date: _______________
SECTION C: EQUIPMENT AVAILABLE
BIOCHEMISTRY ANALYZER
SECTION D: DETAIL OF EXPERIMENT
PLEASE TICK (X) FOR EXPERIMENT DONE
SAMPLE PREPARATION
PLEASE TICK (X) FOR EQUIPMENT NEEDED.
HAEMATOLOGY ANALYZER
AUTOMATED TISSUE PROCESSOR
MICROTOME
CRYOSTAT
TISSUE EMBEDDING SYSTEM
PULVERISER
FREEZE DRYER
AUTOCLAVE
ROTOVAPOR
SONICATOR
OTHERS
EXTRACTION:
STORAGE
*FREEZE DRYER
*Date of Batch 1
*Date of Batch 3
*Date of Batch 2
*Date of Batch 4
*Date of Batch 5
*Date of Batch 6
TYPE OF EXTRACT
**ROTOVAPOR
**Date of Batch 1 **Date of Batch 4
**Date of Batch 2 **Date of Batch 5
**Date of Batch 3 Page 2 of 4
IPPT/SPH/FORM-01
**Date of Batch 6
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SEKSYEN PENYELIDIKAN HAIWAN BAHAGIAN PENYELIDIKAN, PENERBITAN, DAN INOVASI
INSTITUT PERUBATAN DAN PERGIGIAN TERMAJU
SERVICE FORM
Application no.: _______________
Application date: _______________
TRAINING:
RESTRAINING & HANDLING
SEXING
ROUTE OF SUBSTANCE
*PLEASE STATE
OTHERS:
STERILIZATION
LAUNDARY (LAB COAT ONLY) PLEASE STATE
Page 3 of 4
IPPT/SPH/FORM-01
ANIMAL WORK:
ANIMAL SPECIES AGE (WEEKS) SEX
WEIGHT (g) NO OF ANIMALS
DURATION OF STUDY
ANIMAL PROCEDURE:
*METHOD REQUESTED
BLOOD COLLECTION *METHOD REQUESTED
DIAGNOSTIC
LABORATORY EQUIPMENT *PLEASE STATE
PLEASE STATE
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STAFF ASSIGNED
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HEAD OF SPH
REMARK:_______________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________
APPROVAL DATE:_________________________________.
APPLICATION'S SIGNATURE
I HEREBY ACKNOWLEDGE THE INFORMATION GIVEN IS CORRECT.
------------------------------------------- SIGNATURE OF APPLICANT
------------------------
DATE
------------------------------------------- SIGNATURE & STAMP
OF SUPERVISOR/ HEAD OF DEPARTMENT
SEKSYEN PENYELIDIKAN HAIWAN BAHAGIAN PENYELIDIKAN, PENERBITAN, DAN INOVASI
INSTITUT PERUBATAN DAN PERGIGIAN TERMAJU
SERVICE FORM
Application: _______________
Application date: _______________
Page 4 of 4
IPPT/SPH/FORM-01
SEKSYEN PENYELIDIKAN HAIWAN
INSTITUT PERUBATAN DAN PERGIGIAN TERMAJU
SERVICE FORM
Application no:
_______________
Application date:
_______________
SERVICE FORM
This form has 4 pages including 4 sections. Please check the term and condition on page 2 and fill the form
completely. Animal that use for project must be acquired approval from USM Animal Ethics Committee.
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SECTION A: APPLICATION'S DETAIL
PURPOSE OF RESEARCH:
SECTION B: SERVICE PROVIDED
PLEASE TICK (X) FOR SERVICE NEEDED.
Page 1 of 4
IPPT/SPH/FORM-01
*DIAGNOSTIC
SEKSYEN PENYELIDIKAN HAIWAN
BAHAGIAN PENYELIDIKAN, PENERBITAN, DAN INOVASI
INSTITUT PERUBATAN DAN PERGIGIAN TERMAJU
SERVICE FORM
Application no.:
_______________
Application date:
_______________
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SECTION C: EQUIPMENT AVAILABLE
SECTION D: DETAIL OF EXPERIMENT
PLEASE TICK (X) FOR EXPERIMENT DONE
PLEASE TICK (X) FOR EQUIPMENT NEEDED.
EXTRACTION:
Page 2 of 4
IPPT/SPH/FORM-01
SEKSYEN PENYELIDIKAN HAIWAN
BAHAGIAN PENYELIDIKAN, PENERBITAN, DAN INOVASI
INSTITUT PERUBATAN DAN PERGIGIAN TERMAJU
SERVICE FORM
Application no.:
_______________
Application date:
_______________
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TRAINING:
OTHERS:
Page 3 of 4
IPPT/SPH/FORM-01
ANIMAL WORK:
-------------------------------------------
STAFF ASSIGNED
-------------------------------------------
HEAD OF SPH
REMARK:_______________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
APPROVAL DATE:_________________________________.
APPLICATION'S SIGNATURE
I HEREBY ACKNOWLEDGE THE INFORMATION GIVEN IS CORRECT.
-------------------------------------------
SIGNATURE OF APPLICANT
------------------------
DATE
-------------------------------------------
SIGNATURE & STAMP
OF SUPERVISOR/ HEAD OF DEPARTMENT
SEKSYEN PENYELIDIKAN HAIWAN
BAHAGIAN PENYELIDIKAN, PENERBITAN, DAN INOVASI
INSTITUT PERUBATAN DAN PERGIGIAN TERMAJU
SERVICE FORM
Application:
_______________
Application date:
_______________
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Page 4 of 4
IPPT/SPH/FORM-01
8.0.1291.1.339988.308172
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