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Mass Spectrometry Analysis Request Form

To request a mass spectrometry analysis of a sample, please print this form and present it with your sample.

To download the form in Microsoft Word format, click here. (28kb).

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Your Contact Details

Name: __________________________________

Company: _______________________________

or Department: ___________________________

Telephone: ______________________________

Supervisor: ______________________________

Fax: ____________________________________

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Analysis Requirements

Ionisation Mode: [  ] ESI [  ]APCI [ ]CI [  ] EI

Method: [  ] Infusion [  ] LCMS [ ] Solid Probe [  ] GCMS

State Mass Range or Ions to be Scanned: ____________________________________________________ __________________________________________________________________

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Sample Information

Sample Name : _____________________________________________________

Molecular Formula: _______________________________________________

Molecular Weight: _________________________________________________

Stability: Stable [ ] Unstable [ ]

Purity: Crude [ ] Pure [ ]

Solubility (solvent): ________________________________________________

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Toxicity

Does the sample pose any physiological hazard to the analyst [  ]Yes [  ] No

Nature of Hazard if Yes: ____________________________________________

Does the sample contain any buffers or inorganic salts: [  ] Yes [  ] No

If Yes then please state: ____________________________________________

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Office Use Only

Filename: ________________________

Sample ID: ________________________

Notes:___________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________

Samples for ESI and APCI can only be run by Infusion or LCMS.
Samples for CI & EI can be run by Probe or GCMS.

For GCMS or LCMS please supply information on the program used for GC or for LC the column and solvent system used.
Please note limitations as per the Techniques page.

If sending samples by mail they should be sent in an approved mailing tube available at your post office.
Allow extra time for sample dispatch and analysis.

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