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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