Pathology Core Lab Work Request Form

Core Laboratory Contact Information

Patricia Latham, M.D.
Director
202-994-5057

This form should be filled out prior to dropping off specimens. Please make sure your work request form and specimen container have proper identifying information on them.

Basic Information

Investigator

First Name

Last Name

Department

Email Address

Phone

Drop off person/other contact information

First Name

Last Name

Department

Email Address

Phone

Title of the Research

Is the work request for research purposes?

Method of Payment

Type of Funding

Internal (Inside GW): Grant sponsored PTA number

Non grant sponsored funding: Banner ORG/ALIAS number

Source of Funding

Cost center number (if applicable)

Note: Investigators outside of GW requesting work, please make payment via check to the remittance address provided.

Person responsible for payment (Full name as Signature)

I hereby certify that I have personally filled out this form and the information in complete and accurate. By signing this section of this work request, I agree to abide by and be subject to the University's rules, regulations, and disciplinary code. I further understand that it is my responsibility to assure that all documents necessary to complete my work request arrive in a timely manner.

Signature

Work Requested

Type of work requested - Check all that apply

Histology

Frozen Sections

Date Drop Off

Type of Service

Specimen Information

Animal Tissue

Animal Type

Tissue Type (lung, kidney, etc.)

Human Tissue

Tissue Type (lung, kidney, etc.)

Fixative in

Time of Fixative

Sample IDs

Please enter your Sample IDs below:

Histology

Routine Processing?

Routine Embedding?

Embedding Instructions/Orientation Description

Cutting?

Section Thickness (3 microns-routine) - If other, please state:

Total No. slides per block

If levels or serial sections, please explain:

Unstained/block

H&E/block

Special Cutting Instructions

Special Staining

Special stain ordered

Control block/slides provided?

Special Instructions

Immunohistochemistry

Antibody provided by Investigator?

Antibody optimization required?

Control block/slides provided?

If yes, explain the optimization conditions

Additional material provided by Investigator

Special Instructions

Frozen Sectioning

OCT Embed?

Cutting Thickness

How many blocks?

How many slides per block?

H&E/block

Unstained/block

Special Instructions