Project Application Form

 

Send Completed Form To:

Prof. Ronald Kalil, Laboratory Director

rekalil@wisc.edu

 

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: