Central Analytical Research Facility (CARF)

Sample Declaration Form

This form can be used for additional DIY samples or full service samples. Input fields will be popluated according to your selection.
A new CARF Sample Declaration Form MUST be completed and submitted if the description of the sample, biological material or chemical changes.
You can save the form and complete it later by saving the url.
A PDF of your completed form will be forwarded to your nominated email address and your Supervisor (if applicable). Please nominate a CARF staff for review and approval.

Please make sure correct email addresses are provided to avoid delay.

Privacy Notice:
Please note that this form uses Snapforms, an Australian-based online form provider that stores the data in Australia and adhere to the Australian Privacy Principles. The information provided in this form will only be used for the purpose of registering your interests in CARF as a new client so that a kick-off meeting can be arranged with CARF staff and your supervisor to discuss your project proposal in more details. The information provided will be stored securely by CARF and will not be shared with any third party. If you have any privacy concerns, please contact CARF@qut.edu.au.
P.S. You will receive notification emails from "Snapforms Notifications" throughout the workflows.

Your details

First Name *

Last Name *

Sample Category *

DIY samples to be analysed by myselfFull service samples to be analysed by CARF staff

Are you a QUT staff or student? *

YesNo

Staff Username or Student Number *Please use your student number if you are accessing CARF as a student.

Organisation /Faculty /School (non-QUT) *

Organisation Address (non-QUT) *

Please select your QUT Association - Faculty or Research Portfolio *

Please select your school (BAL) *

Please select your school (CIESJ) *

Please select your school (Engineering) *

Please select your school (Health) *

Please select your school (Science) *

Your Position Title *

Other Position Title - please specify

Mobile Phone *

Institutional E-mail *

Primary Supervisor Full Name *

Primary Supervisor E-mail *

Mandatory Health and Safety Information

Please indicate if the submitted samples contain any of the following components. Answer YES or NO to all.

Potential Asbestiform *

YesNo

Fibrous/Potentially N. fibrous *

YesNo

Toxic *

YesNo

Flammable *

YesNo

Radioactive *

YesNo

Explosive *

YesNo

Nano-Materials:Nano-particulate powder *

YesNo

Nano-Materials: Solution based nano-material *

YesNo

Biological *

YesNo

* The term biological includes material of human, animal, microbial, soil, or plant origin or derivation.

Samples are of human origin? *

YesNo

Genetically modified? *

YesNo

Infectious? *

YesNo

Imported on a permit with a condition to use in a QAP? *

YesNo

What is the risk group? *

1234

Fixed or inactivated? *

YesNo

If Yes, what was the treatment? *

The proposed analyses are required to be covered by relevant ethics *

YesNot Applicable

Ethics Number if applicable *

Please provide UN/CAS number or Upload a MSDS *

UN/ CAS numberUpload a MSDS

If your sample is potential asbestiform, toxic, flammable, or radioactive.

UN/CAS Number *

Upload MSDS *

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Please provide UN/CAS # - or upload a MSDS *

UN/CAS #Upload a MSDS

If your sample is explosive, with Nano Powder, Infectious , RG2 or above.

UN/CAS # *

Upload your MSDS *

Browse

Are any materials or items coming into CARF a Scheduled Substances (S2-S9)? - full service samples *

YesNo

Approval number - full service samples *

List S2-S9 items - full service samples *

Please describe samples providing as much information as possible including additional hazards not indicated above. *

Facilities and Types of Analysis

Please discuss with relevant CARF facility if you are unsure what techniques/s you require.

Analytical - Specific details on the analyses requested *

Genomics Analyses

Quality control of genetic materialsSample preparationGenetic sequencingOther (please describe in space below)

Genomics - Specific details on the analyses requested *

Histology Analyses

Histology preparationImage analysisOther (please describe in space below)

Histology - Specific details on the analyses requested *

Optical and Electron Microscopy - Specific details on the analyses requested *

Physical and Mechanical Properties - Specific details on the analyses requested *

Proteomics and Small Molecular Mass Spectrometry Analyses

Other (please describe in space below)

Proteomics - Specific details on the analyses requested *

Surface Analysis - Specific details on the analyses requested *

Vibrational Spectrometry Analyses

FTIRRamanOther (please describe in space below)

Vibrational Spectrometry - Specific details on the analyses requested *

X-ray and Particles - Specific details on the analyses requested *

Please indicate upper size (microns) for Fine Fraction *

Other Analyses not specified above

Reporting of Results

Please discuss with relevant CARF facility stall if the following do not meet your requirements *

Verbal reportsEmail draft resultsProgress reportsEmail report

Sample Disposal Acknowledgement

Sample returned at requester's cost. (If not ticked, samples may be disposed according to individual CARF facility protocols)

Delivery and Packaging

Delivery Address:

Reception, P Block Level 6, Gardens Point Campus,
Queensland University of Technology,
2 George Street, Brisbane, QLD, 4000

SAMPLE PACKAGING REQUIREMENTS:

MUST comply with Australia Post and commercial courier requirements for the transport of non-hazardous materials.

Yes, I acknowledge the above. *

1. Sample Declaration - Chemical Material

I declare that the sample contains chemical material *

YesNo

The term ‘chemical’ includes, but is not limited to, a pure element, a compound of a number of elements, or a mixture of two or more such compounds, and any solution, suspension, fume or aerosol thereof. Chemical materials also include rocks, minerals, oils, soils (which is also a biological material).

Section 1. Chemical Material

All work with hazardous chemicals must comply with the QUT Chemical Management Procedure.

What is the chemical material? *

In what form is the material? *

Other form of the material: *

How will the chemical material be used? *

What chemicals are in the material? *

Chemical sample disposal type: *

Please specify the sample disposal type. *

Storage and disposal instructions: *Please note that samples cannot be stored in CARF and will be disposed according to the instructions if necessary.

Are any chemicals classified as a hazardous chemical? *

YesNo

Is this chemical material classified as a nano-particulate material? *

YesNo

Please refer to the QUT High Risk Chemicals and Red Flag Guideline and HSE Chemical Management - Annex F - QUT High Risk Chemicals for answering the following questions:

Are any chemicals on the QUT High Risk Chemical List? *

YesNo

Chemicals of Security Concern? *

YesNo

Security Sensitive Ammonium Nitrate? *

YesNo

Cryogenic Liquids? *

YesNo

Radioactive Materials? *

YesNo

Chemical Warfare Agent Precursors? *

YesNo

Prohibited and Restricted Carcinogens? *

YesNo

Drugs and Poisons? *

YesNo

Dangerous Goods? *

YesNo

Illicit Drug Precursors? *

YesNo

Controlled Substances *

YesNo

Do you intend to undertake non-ambient (heating/cryo) XRD techniques on the sample? *

YesNo

If yes, please add yourself to the XRD High Temperature MAPS (10360)

If you have ticked yes to at least one of the above. Please provide further information: Chemical Name, UN No. CAS No. Form, Conc, Quantity, DG Class (all required) - or indicate the information is uploaded in the field below.

Please upload information on other chemical materials for your projects here:

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Scheduled Substances (S2-S9)

Are any materials or items coming into CARF a Scheduled Substances (S2-S9)? *

YesNo

Approval Number # *

List S2- S9 items *

2. Sample Declaration - Biological Material

I declare that the sample contains biological material *

YesNo

The term ‘biological material’ includes material of human, animal, microbial or plant origin or derivation.

Section 2. Biological Material

All work with biological material must comply with the QUT University Biosafety Committee (UBC), Animal Ethics Committee (UAEC) or Human Research Ethics Committee (UHREC) conditions of use. Please provide relevant Approval Numbers below.

UAEC Approval No. (if required)

UHREC Approval No. (if required)

What is the biological material? *

How will the biological material be used? *

Fixative and/or inactivation treatment *

Biological sample disposal type *

Please specify biological sample disposal type *

Storage and disposal instructions: *Please note that samples cannot be stored in CARF and will be disposed according to the instructions if necessary.

1. Is the biological material genetically modified (i.e., GMO, GM plant)? ^ *

YesNo

UBC Approval No: *

2. Has the biological material been imported on a Permit with a Condition requiring permanent containment within an approved arrangement site? ^ *

YesNo

Permit No.: *

3. Is the biological material infectious to animals or humans? ^ *

YesNo

4. Was the biological material sourced from outside QUT? *

YesNo

Organisation: *

5. Was the biological material collected from a field site (biosecurity movement restrictions may exist)? *

YesNo

Site Location: *

^ If you answered 'yes' to any of 1, 2 or 3, the material can only be used in GP-R413-422.

Microorganism Risk Group: (* Group 3 and 4 cannot be brought into CARF labs) *

123* 4*

Sample Identification

Please provide sample identification below - "Sample ID Number" and "Sample Name". If you prefer to upload a file, please put in "See file attached" in both fields and upload your file.

Sample ID Number *

Sample Name *

Upload Sample Identification

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Please upload your sample identification in two columns: A) Sample ID Number and B) Sample Name

Please nominate a CARF staff for approval *

Please nominate a CARF staff *

Signature and Date

Signature *

Draw signature|Type signatureClear

DATE *

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Upon submission, a PDF copy of this form will be send to you, your nominated CARF staff and primary supervisor (if applicable).

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