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Micro-Imaging Research Facility- Usage Agreement 
Center for Dental Research, Loma Linda University School of Dentistry

Instruction: One form for each project;

Section 1: User Information

Section 2: Analysis

Section 3: Project Information

Project Description: Please provide an abstract/summary including a) hypothesis, b) groups including the number of samples to be imaged, c) parameters for the SEM, d) anticipated problems, and e) other information relevant to imaging and analysis. The information is used for SEM equipment and analysis, and will be kept confidential.

Files must be less than 2 MB.
Allowed file types: jpg jpeg png txt pdf doc docx.

Researchers authorized to plan and schedule experiments (Last Name, First name). If you have extramural collaboration, specify colleague institution, e-mail, and phone number.

Section 4: Budget Estimation

Estimates:

$

BY SUBMITTING THIS FORM:

I acknowledge that I am voluntarily providing my personal information to Loma Linda University Health. I understand that in order to keep my health information private, I will abstain from using this form to provide details about my medical condition or that of the individual I am requesting information for. I will limit the amount of information shared on this form to only my contact information in order to receive the requested information. I understand that I may contact Loma Linda University Health directly at 855-558-1100 in case I need to discuss confidential or private information. I further understand that I may be contacted by a representative from LLUH in response to my inquiry via telephone or mail. I understand LLUH will not respond via email when communicating confidential or private information

Authorization Signatures: