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

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

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

-------------------------------------------

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: _______________

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

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