GentleMACS Use Request Form Submitter Name* First Last Submitter Mobile Telephone Number*Submitter Email* Affiliation*If you are not a BU student, staff, or faculty member, or if your project funding is not provided via a BU associated grant, please choose "External."BUExternalDepartment* Institution/ Company* P.I. Name* First Last P.I. Email* Grant Administrator Name* First Last Grant Administrator Email* Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Grant Account Number* If you are an non-BU investigator, please indicate your invoice number or "Invoice Pending." If you are a BU investigator and have not been given your account number by your grant administrator, please indicate "Account Number Pending."GentleMACS Tissue DissociationNumber of Samples*Sample Species*HumanMouseOther"Other" Sample Species Do your samples contain a potentially infectious agent?*For example: Have your sample cells or tissues undergone infection with bacteria or virus? All clinical samples from human subjects are considered potentially infectious.YesNoDo Not KnowAre your cells from clinical human subjects samples?*YesNoNotesAcknowledgementsPlease read and acknowledge each statement below in order to submit your request.Instrument Use Agreements*I understand that I am scheduling an appointment to use the GentleMACS instrument to dissociate my tissue myself, not requesting the Single Cell Core dissociate tissue for me. Agree I understand that I am scheduling an appointment to use the GentleMACS instrument to dissociate my tissue, not requesting instrument training from the Single Cell Core.*I understand that I am scheduling an appointment to use the GentleMACS instrument to dissociate my tissue, not requesting instrument training from the Single Cell Core. Agree I understand that should the GentleMACS instrument malfunction or break during my appointment, I agree to *immediately* report the incident to a member of the Single Cell Core.*I understand that should the GentleMACS instrument malfunction or break during my appointment, I agree to *immediately* report the incident to a member of the Single Cell Core. Agree Safety Agreement*I acknowledge that information I have provided in this form about sample source and biosafety is accurate. Agree I agree that I will wear an appropriate face mask while processing samples in the Single Cell Core.*I agree that I will wear an appropriate face mask while processing samples in the Single Cell Core. Agree I agree that I will meet social distancing guidelines by remaining 6 feet from Single Cell Core researchers during sample processing.*I agree that I will meet social distancing guidelines by remaining 6 feet from Single Cell Core researchers during sample processing. Agree I agree that I will comply with safe conduct requests made by Single Cell Core researchers during sample processing.*I agree that I will comply with safe conduct requests made by Single Cell Core researchers during sample processing. Agree I agree that I will disinfect all instrument and laboratory space surfaces after sample processing is complete and before departing the Single Cell Core.*I agree that I will disinfect all instrument and laboratory space surfaces after sample processing is complete and before departing the Single Cell Core. Agree Appointment*After hitting "Submit" below, you will be redirected to our GentleMACS appointment calendar. Please book an instrument use appointment in conjunction with submitting this form. Investigators who do not book an appointment will not be permitted to use the instrument. Agree CommentsThis field is for validation purposes and should be left unchanged.