GWU School of Medicine and Health Sciences Histopathology Work Request Form

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vyGapSVTzqtPH4osj9UpyWDkMbMujazFK3fqcaNV7yBtEkjiGRwuNL5QCJaD2hgeWgdLNBe9FBCEYPCWNAgyzq53

Histopathology Research Core

Ross Hall Room 124

Please fill out the form below to submit a work request for the GWU Histopathology Core. Thank you!

Requestor Information	Name: Email: Department:
Principal Investigator Information	Name: Email: Department: P.I. center membership:
Contact Phone Number:
Title of Research:
Request Submission Date:

Funding Type:

* must provide value

Internal External

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Company/Organization Name:
Note: Investigators outside of GW requesting work, please make payment via check to the remittance address provided

* must provide value

Account Type:

Program ID:

* must provide value

Banner ORG/ALIAS number:

* must provide value

Tissue Origin:

Organ/ Tissue Type:

Specimen Type:

Number of Specimen:

Specimen IDs:

Fixative Used:

Time in Fixative:

Transport Media:

What Type of work are you requesting?

* must provide value

Processing Embedding Sectioning Staining Slide Imaging Pathologist Review Frozen Sections

Who will perform the embedding?

Service Performed by Lab Self Service

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Embedding Information:

Embed only?

Embedding Medium:

Embedding Orientation:

Who will perform the sectioning?

Service Performed by Lab Self Service

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Sectioning Information:

Sectioning Type:

Number of Sections per slide:

Section Thickness (um):

Tissue Orientation on Slide (Please Describe)

Per Block:

Type(s) of Stains:

Unstained Count:

Slide Thickness (um):

H&E Count:

Slide thickness

Scrolls Count:

Slide Thickness (um):

Special Stains / IHC Count:

Slide Thickness:

Special Stain/IHC information:

Control slide provided?

Stain Requesting:

Optimization Required?

Other Testing Needed:

Who will perform the Slide Imaging?

* Training is required before independent operation of the VS200 Slide Scanner.

Service Performed by Lab Self Service

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Slide Imaging Magnification:

* must provide value

10x 20x 40x

Comments / Special Instructions:

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Please schedule a specimen drop off time using the calendar link here.

Please schedule an embedding time using the calendar link here.

Please schedule a sectioning time using the calendar link here.

Please schedule a slide imaging time using the calendar link here.

* If you are scheduling a training session, please reserve a two‑hour time slot and note "VS200 Slide Scanner Training" in the comment section.

I hereby certify that I have personally filled out this form and the information in complete and accurate. By signing this section of this work request, I agree to abide by and be subject to the University's rules, regulations, and disciplinary code. I further understand that it is my responsibility to assure that all documents necessary to complete my work request arrive in a timely manner.

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