Application for Appointment as Visiting Investigator or Guest

Form submitted to Director of Research

Part I: Personal Information

Name:

Position:

Institution:

Street/P.O. Box

City

State
 Zip
 Country/Code

Phone:

Email Address:

Sex:
Male     Female

Date of Birth:

Citizenship:

Social Security Number:

Period of Appointment:

Jackson Laboratory Sponsor:

You will need to mail your CV and your Research Proposal (500 word maximum) to The Jackson Laboratory.
 

Part II: Housing

The Jackson Laboratory operates six 2-bedroom cottages, known as the Woodlands Cottages, which are available to Visiting Investigators and Guests during June thru September. These cottages, which are located one-quarter mile from the Laboratory, are fully furnished except for linens. A use fee is charged and no pets are permitted. If you wish to be considered for a Cottage, please provide the information requested below.

Check here if you wish to be considered for a Woodlands Cottage.
      How many people will there be in your party?

Part III: Research Facilities

   

Yes

No

Provided
by Sponsor

1. Lab Space
2. Office Space(contingent on availibility)
3. Animals (if Yes, see Part IV)
4. Supplies & Equipment (if Yes, see Part V)
5. Biological material, tumor lines (if Yes, see Part V)
6. Radioisotopes/X-ray Equipment (if Yes, see Part VII)
7. Carcinogens/mutagens/teratogens (if Yes, see Part VII)

FacilitiesUtilization
In order to help us anticipate requirements for research space and facilities, please indicate below the approximate percentage of time during the period of your appointment that you expect to be physically present at the Laboratory (include time at the bench, in consultation, and in the Library.)

Lab/Animal Space 25% 50% 75% 100%
Office Space 25% 50% 75% 100%

Part IV: Animal Use

Much of the research at The Jackson Laboratory is based upon irreplaceable colonies of laboratory animals. Introduction of infectious diseases could have disastrous consequences not only for research at the Laboratory, but also for research programs elsewhere that depend upon our animals. Therefore, we require that all visitors observe the regulations summarized in thedocuments entitled “Visitor Regulations”, “Procedures for Bringing Equipment and Non-biological Research Materials to The Jackson Laboratory”, and “Policy on Importation of Animals & Biological Materials.”

Will your proposed research at The Jackson Laboratory involve the use of animals or animal tissues?
Yes     No

If you answered Yes, is your proposed research part of your Sponsor’s on-going research program and included in their approved animal protocol?
Yes     No

If No, complete the Animal Protocol Form (APF). If you have questions about completing the APF, please contact the ACUC Coordinator at (207) 288 6282.

Part V: Equipment

Will you bring equipment to The Jackson Laboratory?
Yes     No

If yes, please list equipment and indicate which equipment items of any will come in contact with animals.

  Direct Contact Indirect Contact
Item:
Item:
Item:

Part VI: Personal Health

1. The Jackson Laboratory Employee Health Office will ask Visiting Investigators to complete a health/medical questionnaire if he/she will be at the Laboratory for longer than three (3) months. The reason for this is to be alerted to any potential occupational health risks for the individual. For example, a person that comes to The Jackson Laboratory with a history of allergies and/or asthma may have a potential possibility of exacerbation of allergy symptoms if mouse room work was going to be a part of the work or research to be done. After review of the completed form, the Manager of the Employee Health Office will call for information or clarification or to set up an appointment, if necessary, once the person is on campus.

2. If a Visiting Investigator or Guest requires accommodation for a medical problem or condition, it would be advisable to call the Employee Health Office in advance of arrival to The Jackson Laboratory.

For more information, please call the Manager of Employee Health Office at (207) 288 6096.

Part VII: Safety

Radioisotopes:

Will your proposed research at The Jackson Laboratory involve the use of radioisotopes?
Yes     No

If yes, what radioisotopes and amounts do you plan on using?

Will your proposed research at The Jackson Laboratory involve the use of X-Ray producing equipment?
Yes     No

If yes, what X-Ray producing equipment will you use?

Individuals planning on conducting research involving radioisotopes and/or X-Ray producing equipment will need to complete the Registration and Radiation Badge Request Form.

Will you bring chemicals or drugs to The Jackson Laboratory?
Yes     No

If yes, please list names of chemicals, drugs or other supplies.

Are any of these supplies controlled substances or prescription drugs?
Yes     No

If yes, indicate by C (controlled) or P (prescription) drugs in the list above.

Carcinogens/Mutagens/Teratogens:

Will your proposed research at The Jackson Laboratory involve the use of any carcinogens, mutagens, and/or terotogens?
Yes     No

If yes, please list them and the amounts that will be used.

Will you bring biological materials, such as, transplantable tumor plasma, ascites fluids, cell cultures, cell-culture products, blood, sera, plasma to The Jackson Laboratory?
Yes     No

If yes, please provide the following information:

Name of biological material: Proposed In-Vivo Use In Vitro