Download SUPPLEMENTAL FORM 4 Drug Administration The University at

SUPPLEMENTAL FORM 4
Drug Administration
The University at Albany – IACUC
09.01.09.1
ORRC use only
Protocol #
[Note]
PI NAME
Form 4 contains following sections; please complete all applicable section(s).
Page 1 Drug List: (for All PIs whose protocol involves ANY KIND OF DRUGS).
Please fill out if applicablePage 2 Section1: drugs used for sedation, anesthesia, analgesia, or tranquilizers.
Page 3 Section 2: Use of Paralyzing agents or Neuromuscular Blocking Agents
Note1: If the protocol involves other controlled substance (such as narcotics, carcinogens, infectious agents
etc), test substance, or biological, chemical, toxic, or radioactive substance, PI needs to submit Form 5:
Substance Administration form.
NOTE2: If your laboratory has written Standard Operation Procedures (SOPs) of drug administration,
please cite SOP #. The IACUC strongly recommends that each laboratory have IACUC approved SOPs for
all experimental procedures.
1. Provide following information:
Yes
No Will you utilize drugs used for sedation, anesthesia, analgesia, or tranquilizers to
animals? -If “Yes”, please also complete page 2.
Yes
No
Will you utilize Paralyzing or Neuromuscular Blocking Agents to animals?
-If “Yes”, please also complete page 3.
2. Please provide the following information for drug(s) that you intend to utilize in this
protocol other than sedation, anesthesia, analgesia, or tranquilizers, Paralyzing agents,
Neuromuscular Blocking Agents.
Duplicate the table as often as required.
Name of Drug
Dosage
(mg/kg, %, conc.)
Volume (ml
etc)
Route and
Size of Needle
(if applicable)
When and how often will it be
given?
ROUTE:
NEEDLE SIZE:
ROUTE:
NEEDLE SIZE:
ROUTE:
NEEDLE SIZE:
ROUTE:
NEEDLE SIZE:
ROUTE:
NEEDLE SIZE:
NOTE: The use of expired medical materials such as drugs, fluids, or sutures on animals is not considered to be
acceptable. PIs are expected to use pharmaceutical-grade medications whenever they are available, even in
acute procedures. Non-Pharmaceutical-grade chemical compounds should only be used in animals after specific
review and approval by the IACUC for reasons such as scientific necessity or non-availability of an acceptable
veterinary or human pharmaceutical-grade product. Any compounded drugs must be prepared and administered
sterile according to regulations.
Section 1: sedation, anesthesia, analgesia, or tranquilizers
Provide following information: Duplicate the table as often as required.
**If your laboratory has written Standard Operation Procedures (SOPs) for drug administration, please
provide a copy along with this form. The IACUC strongly recommends that each laboratory have IACUC
approved SOPs for all experimental procedures** SOP #
Name of sedation, anesthesia, analgesia,
or tranquilizers
Dosage (mg/kg, %, conc.)
Route and size of needle
Frequency of Administration
Volume (ml etc)
Timing (when) of Administration
Route:
Needle Size:
Purpose of Administration
Name of sedation, anesthesia, analgesia,
or tranquilizers
Dosage (mg/kg, %, conc.)
Route and size of needle
Frequency of Administration
Volume (ml etc)
Timing (when) of Administration
Route:
Needle Size:
Purpose of Administration
Name of sedation, anesthesia, analgesia,
or tranquilizers
Dosage (mg/kg, %, conc.)
Route and size of needle
Frequency of Administration
Volume (ml etc)
Timing (when) of Administration
Route:
Needle Size:
Purpose of Administration
Name of sedation, anesthesia, analgesia,
or tranquilizers
Dosage (mg/kg, %, conc.)
Route and size of needle
Frequency of Administration
Volume (ml etc)
Timing (when) of Administration
Route:
Needle Size:
Purpose of Administration
FORM 4 // Page 2 of 3
Section 2: Usage of Paralyzing / Neuromuscular Blocking Agents
Paralyzing / Neuromuscular-blocking Agents can conceal inadequate anesthesia and therefore
require special justification. If you are using such an agent, please provide following information:
**If your laboratory has written Standard Operation Procedures (SOPs) for drug administration, please
provide a copy along with this form. The IACUC strongly recommends that each laboratory have IACUC
approved SOPs for all experimental procedures** SOP #
Duplicate the table as often as required.
Name of Agents
Dosage (mg/kg, %, conc.)
Route and Size of Needle
Frequency of Administration
Volume (ml etc)
Timing (when) of Administration
Route:
Needle Size:
Duration of Paralysis state
Provide detailed information below
Purpose of usage of Paralyzing Agents; provide scientific justification

What physiological parameters are monitored during the procedure to assess adequacy of
anesthesia?

Under what circumstances will incremental dose of anesthetics-analgesics be administered?
FORM 4 // Page 3 of 3