Project Application Form

Send Completed Form To:

Lance Rodenkirch, Laboratory Manager

University of Wisconsin

W.M. Keck Laboratory for Biological Imaging

1300 University Avenue, Madison WI 53706

If you have any questions about the form, please call the Laboratory office at: (608) 265-5651

Date:

Title of Project:

Keywords (3-5):

Principal Investigator on Grant Supporting Research:

Title & Degree:

Department:

Address:

Phone: _______________FAX:_________________ Email:____________________

Institution or Organization: UW-Madison___UW-System___ Other___

If Other Please Specify:

Agency & Grant #:

Hands On User: Yes___ No___

Assurances:

As Principal Investigator on this Keck Laboratory for Biological Imaging subproject, I agree to:

1. Acknowledge the use of the Keck Laboratory for Biological Imaging, UW-Madison in any

resulting publications.

2. Send two reprints of each resulting publication to the Keck Imaging Laboratory at The University of Wisconsin-Madison and be willing to supply representative images.

3. Approve payment of user fees incurred by this project.

4. Review progress with Keck staff.

5. Be responsible for any damage resulting from misuse.

Signature of P.I. _________________________ Date:_________________

Investigator 1: Title & Degree: Department: Address: Phone:________________ FAX:_________________ Email: _______________________________ Institution or Organization: UW-Madison___UW-System____ Other ____ If Other Please Specify: Agency & Grant #: Hands On User: Yes___ No___	Investigator 2: Title & Degree: Department: Address: Phone:________________ FAX:_________________ Email: _______________________________ Institution or Organization: UW-Madison___UW-System____ Other____ If Other Please Specify: Agency & Grant #: Hands On User: Yes___ No___
Investigator 3: Title & Degree: Department: Address: Phone:________________ FAX:_________________ Email__________________________________ Institution or Organization: UW-Madison____UW-System_____ Other____ If Other Please Specify: Agency & Grant #: Hands On User: Yes___ No___	Investigator 4: Title & Degree: Department: Address: Phone:________________ FAX:_________________ Email: ________________________________ Institution or Organization: UW-Madison___UW-System_____ Other____ If Other Please Specify: Agency & Grant #: Hands On User: Yes___ No___

Project Details:

1. Please attach an abstract describing your project in 100-150 words.

2. Include any publications that you feel are relevant.

3. Provide any other information you feel is relevant.

Projected Use (Hours per week):

Confocal ____

Image analysis ____

Does the Project Involve:	NO	YES	Approval is: (circle one.)
1. Toxic, infectious, carcinogenic/mutagenic material of proven or potential hazard to humans, other animals or to plants? Use of recombinant DNA technology?			pending	attached
2. Use of human subjects or human tissue?			pending	attached
3. Use of vertebrate animals?			pending	attached

Keck Staff Use:

Project#:____________Date Approved:____________

Equipment Requested:

Hours: Confocal:______Workstation:_______Staff:_______

Training Date:_________Hands on Completed:__________

Fees: Charged:_____Collected:_____Updated:__________

Staff Comments: