ANIMAL USE FORM

Name of principal investigator: ______________________________________

Title of Proposal: ________________________________________________

Do you have a permit to use laboratory animals?^*       Yes      No

If yes, provide permit number:                      

            Specie(s) of animals:               Strain(s):                    

            Number of animals:               Time period:                  

List procedures to be carried out on animals (include venipunctures and injections):

1.                                                          4.                                            

2.                                                          5.                                            

3.                                                          6.                                            

Will the animals receive a special diet?      Yes      No. If yes, describe.

 Does this project involve survival surgery?       Yes       No    

What anesthetic, if any, will be used? Give name (generic), dose and route of administration.

Where will the animals be housed?                        

Animals will sustain      minimal      moderate      severe pain.

Will any drug(s) be administered to relieve pain or as prophylaxis against infection?    Yes      No     

If yes, give generic name and doses.

Mention other methods that will be used to ensure that no undue discomfort, distress, pain or injury will occur to the animals.

What other drugs will be administered? (Name, dose, duration, and expected effects).

Will radioactive material be administered to animals?        Yes        No

If yes, indicate type and dose, and handling and disposing of the animal.

Method of euthanasia:                                              

^*All researchers whose work involves handling of animals will be required to attend a session on use of laboratory animals to be set at a later date.