Pathology Core Lab Work Request Form

Core Laboratory Contact Information

Patricia Latham, M.D.
Director
202-994-5057
Rose Webb
Lab Manager
202-994-8916

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 purpose?

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
EM
* 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

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