Download Proposal to Use Animals in Patient Care Areas at UNMC/NM

Proposal to Use Animals in Patient Care Areas at UNMC/NM
Refer to Policy for Animal Use in Public/Patient Care Areas on IACUC Website
*This form must be completed and submitted to the Comparative Medicine Safety/ Compliance Program Manager
for final approval. Comparative Medicine: [email protected], 9-4034, Fax: 9-3222, Zip: 5810.
Principal Investigator Name/Phone:
IACUC Protocol #:
Species:
Location/Clinical Area of Procedures:
Number of times this procedure area will be used:
Dates/Time of Procedures:
Length of Procedure:
Provide a description of Secure Transportation Enclosure. Animals must be secured to prevent escape and covered from
public view:
Anesthesia during Transport and Procedures: (Please circle one)
Yes
No
Has written approval of the Clinical Department Head been obtained? (Please circle one) Yes
Please have Department Head sign below.
No
Describe the actual route that will be taken to move the animal/s from the CM Facility to the procedure area:
(Contact CM for current, approved routes)
Please describe the appropriate arrangements that have been made with department staff or Environmental Services for
posting the room during the procedure and clean/up disinfection of the clinical area:
*Reserve the HEPA filtration unit online through RSS and make arrangements with CM for pick up and return.
Approval
Please print name and sign: ____________________________________________________________
Department Chair or designee of patient care area
Date
Please print name and sign: ____________________________________________________________
Department of Infection Control and Epidemiology
Date
Please print name and sign: ____________________________________________________________
Safety/ Compliance Program Manager, Comparative Medicine
Date
03/16/2016