Tufts CMS Animal Export Form

Animal Exportation Form

Please complete this form if you are planning to export research animals from Tufts to another institution and are requesting a health report be sent from Tufts CMS to another facility.

Please refer to Animal Export Guidelines for further information. All forms and guidlelines can be found on the Tufts CMS website. Contact TuftsCMS-exports@tufts.edu for any questions.

Tufts Information

PI Name*

PI email*

PI Email*

Name of person completing this form*

Email of person completing this form*

Additional lab contact name (optional)

Additional lab contact email (optional)

Who will pay the export fee and shipping supply costs*

Tufts/Tufts Medical Center InvestigatorRecipient Investigator

Who will pay the courier costs?*

Tufts/Tufts Medical Center InvestigatorRecipient Investigator

Billing Account #*

Preferred courier account to use for export (not required)

Recipient Information

Receiving Institution Name*

City

State

Country

Recipient PI Name*

Recipient PI Email*

Lab Contact Name

Lab Contact Email

Animal Facility Contact:

Please list the name and email of at least one person such as a veterinarian or animal importation coordinator in the recipient animal facility who should receive the health report. This is generally NOT someone from the research laboratory.

Health Contact Name

Health Contact email*

Other contacts:

Please list emails (separated by a semicolon) for anyone else besides those contacts already listed who should be included on correspondence regarding this shipment

Animals

Species*

Total number of cages for export*

if the total changes prior to shipment, please notify us

total # females to be sent*

total # males to be sent*

Room number where animals are housed*

When will the animals be ready to ship?

All animals are ready and available nowThe animals will be ready to send soon (within 2 weeks)The animals will not be ready to send for at least a monthOther

Are there any critical timing issues of which we should be aware or make the recipient institution aware?

If multiple shipments are planned to this recipient in a short time frame (usually under 2 months), please describe the plan and timeline

List all strains/stock/genetic mutations. If you have more than 5 different genotypes of animals for export, list the remainder in the notes section.

1.

strain/genotype*

# F*

#M*

2.

strain/genotype

# F

#M

3.

strain/genotype

# F

#M

4.

strain/genotype

# F

#M

5.

strain/genotype

# F

#M

Notes and space for additional animal groups.

Technology Transfer

The following questions relate to the possible need for material transfer agreements (MTA) between Tufts University or Tufts Medical Center and the recipient institution or between other institutions and the recipient institution. An MTA must be in place before shipping or receiving any genetically modified animals. Please contact mta@tufts.edu (Tufts University) or Tuftsmcgrants&contra@tuftsmedicalcenter.org (Tufts Medical Center) to determine if an MTA is required before shipment of the animals.

Name of source institution where genetically manipulated animals or animals used for crossbreeding were originally created*

Were these animals created at Tufts?*

Yes, by genetic manipulationYes, by crossbreedingNoOther

Name of the original providing scientist of the animals

Has the source institution given permission for this transfer?*

YesNo

Notes to our staff regarding any technology transfer information

Check all that apply

the animals have a known immunodeficiencythe animals have a phenotype that causes illness, abnormalities, or early deaththe animals require special husbandry such as special diets, medical treatments, sterile caging, etc.None of the above apply

Describe the immunodeficiency*

Describe the need for special caging, diets, or medical treatments*

Describe phenotypes with severe illness, abnormalities, or early death.*

Have these animals been experimentally exposed to any biohazardous agents or hazardous chemicals?*

YesNo

If yes, what infectious agent(s) or chemical(s)?

Final Notes (optional)

Notes to the Tufts CMS export staff or notes that you would like us to include in correspondence to the recipient facility: