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National Institutes of Mental Health Order Information Form

Name of agent to be tested:

Amount:

Brief description of intended use and importance of research to neuroscience:

Please click on boxes where you can provide the following data:

Binding affinity (Ki) of the unlabeled ligand at cloned human receptors

Information on lipophilicity measurements

Information on MTD data by iv route (rodents) or information about iv dose range finding studies

Information regarding in vitro autoradiography studies in the brain (rodents)

Information regarding in vivo biodistribution studies

Information regarding competitive inhibition studies (rodents)

Information on in vivo metabolism studies (rodents)

Information on in vitro metabolism studies in rat and human hepatocytes

Information on ex vivo autoradiography studies (rodents)

Information regarding in vivo pharmacology and/or PET studies (primates)

Information regarding dosimetry studies (rodents)

Bioanalytical methods for detection of plasma levels

Analytical methods development

Formulation of compound

Source of financial support for the proposed research

Priority for assignment of NIMH resources will be based on which agents have the most complete data packages; i.e., investigators who can provide information in all of the requested areas below will be given highest priority.

Primary source of funding for proposed research:

Name of scientist requesting assay(s): *

Mailing address:

Telephone/Fax Numbers: *

E-Mail Address: *

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