Pathology / Histology Image Request Form

Pathology / Histology Image Request Form

Pathology Histotechnology Laboratory, FNLCR V 04_25_16

Request #

Contact Information
(Required) / NCI-F Project IDs are required for all submissions. CSAS# are additionally required for all non-NCI submissions. Details at:
Name: / Bldg/Rm: / Phone: / Email:
NIH Institute: / Lab: / NCI-F Project ID: / CSAS #:
Animal Study Proposal: / Date:
Image Capture Desired Magnification (Native Resolution)
☐ Macropath (gross photo)
☐ Bright field Whole Slide Scan (Aperio)@ ☐5x ☐20x ☐40x
☐ Bright field/Fluorescent Single Field @☐2x ☐4x ☐10x ☐20x ☐40x ☐60x ☐ 100x
Select all that apply: ☐DAPI☐ FITC ☐Rhod☐☐GFP☐RFP ☐RFP☐YFP
☐Texas Red
☐Alexa ☐Alexa ☐Other
Image Annotation and Extraction
☐Extract Single field from whole slide scan ☐1x ☐ 5x ☐20x ☐40x
☐Annotation
Image Analysis/Quantitation
☐Positive Pixel Count (Aperio) ☐PCNA ☐BrDU☐gH2AX (fluorescent)
☐TUNEL/Apoptag☐Micro vessel count ☐Nuclei count☐Other ______
Specimen Information
PHL # / Specimen ID / Stain / Fixative / Target / Species / Tissue
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Comment:
Specimen Information cont.
PHL # / Specimen ID / Stain / Fixative / Target / Species / Tissue
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