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Required format:

FFEWfcCMIzexk7AdQKATqv8KhPishCgSD8xYkY3guXuceifmmMNoJI78Tx39J25

Biorepository Resource Request Form

The equipment can only be accessed during business hours (M-F: 8.00AM – 5PM). The EVMS Biorepository Staff must be notified 24 hours ahead of time if you need to reschedule or cancel. Without prior notification, a no-show will cost you a full-hour’s charge. If you are late for a scheduled session, you will be charged based on your reserved start time.

Last Name

* must provide value

First Name

* must provide value

E-mail Address

* must provide value

Organization

* must provide value

Department

Preferred Reservation Date

* must provide value

D-M-Y

Preferred Starting Time
(Please choose a time between 8 a.m. and 4 p.m.)

* must provide value

H:M

Preferred Ending Time
(Choose a time no later than 5 p.m.)

* must provide value

H:M

Alternate Reservation Date

D-M-Y

Alternate Starting Time
(Please choose a time between 8 a.m. and 4 p.m.)

H:M

Alternate Ending Time
(Choose a time no later than 5 p.m.)

H:M

Billing/Account Number

* must provide value

Are you affiliated with EVMS?

* must provide value

Yes

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Services Needed

* must provide value

Cryostat (self service) - one time training ($20/hr EVMS, $30/hr external), usage ($10/hr EVMS, $15/hr external)

Microtome (self service) - one time training ($20/hr EVMS, $30/hr external), usage ($10/hr EVMS, $15/hr external)

Obtaining patient consent ($10/hr EVMS, $15/hr external)

-80 Storage - per 1 month, per box ($10/hr EVMS, $15/hr external)

IRB Revision ($35/hr EVMS, $52.50/hr external)

Pathologist services - per hour ($100/hr EVMS, $150/hr external)

Sample pick-up and transfer ($10/hr EVMS, $15/hr external)

Fluid specimen processing - simple ($10/hr EVMS, $15/hr external)

Fluid specimen processing - complex ($20/hr EVMS, $30/hr external)

Request Notes
(Please use this area to tell us more about your study and/or needs.)

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Note: Requester will provide all consumables. If consumables or histology services are needed,
please contact the Biorepository at 757.446.7910 or email Mary Ann Clements for a quote.

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