Service Request Form

RARAF – Service Request Form

Please respond as best you can to all of the questions below. This information is necessary in order to provide the services that will be required as efficiently as possible.

If you prefer to fill out this form offline, a PDF version is available for download.

*	Principal Investigator:
*	Title of Experiment:
**	Funding Agency:
**	Grant Number:
**	Grant Title:
*	Email:
	Institution:
	Department:
	Address:

	City:
	State:
	Zip Code:
	Country:
	Phone:
	FAX:

* denotes a required field.

** Source of funding for this work.

Abstract of proposed experiment:

What type of beam will you need? Particle Type: Energy/LET: Dose: Dose Rate:

Other beam requirements (please specify):

Please estimate when the experiment will be ready to run:
Estimate the total scheduled time required:
How many runs will this experiment entail?
What is the anticipated duration of a typical run?
Over what time span will runs be separated (days, weeks, months)?
How many days notice is required in case of a change in scheduling?
Will someone come in person or send samples?
Will someone be bringing hazardous materials/equipment?
If yes, please specify:

If someone is coming in person to RARAF, who will come?

Name	Title	Phone Number	Email

What is/are the most important parameter(s) to control for this experiment?
(if more than one, please prioritize)

Discuss the technical aspects of this experiment.

What cell culture or animal facilities will you need?

What other support will need to be provided by the RARAF staff?

I accept responsibility for ensuring that this experiment is conducted in a safe manner.

Further, if any results obtained using RARAF are inculded in a paper or abstract:

I agree to explicitly acknowledge RARAF funding sources in all such papers / abstracts (see instructions), and
I agree to pass all such papers or abstracts by a member of the RARAF staff before submission in order to check that references to RARAF are accurate (see instructions), and
I agree to send two reprints of any such abstracts or papers concerning RARAF to the RARAF staff (see instructions).

Signature of principal investigator (please type your name):

Date:

Site developed by CE, page last modified by JL on July 13, 2009 .

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