Please Fill out Completely. Incomplete Forms Will Be Returned and Training Will Not Be

Center for Comparative Medicine / IACUC Animal Care & Use Questionnaire

Please fill out completely. Incomplete forms will be returned and training will not be scheduled.

CONTACT INFORMATION First name Last name Gender Job Title Highest degree Department Office location Phone number Email address PI’s name Employee ID / or Date of training last 4 ssn requested Date of Birth Position name

SKILLS AND EXPERIENCE

1. Have you had any previous training in the use of laboratory animals?  No  Yes Please complete table on page 2

2. What species are you going to use?  Birds  Cats  Chinchillas  Fish  Gerbils  Guinea pigs  Hamsters  Mice  Rats  Nonhuman primates  Unknown  Other: ______

3. What procedures are you likely to use on animals?  Handling  Injections  Euthanasia  Survival surgery  Husbandry  Non-survival surgery  Post-procedural monitoring  Use of restraints  Other: ______

4. Will you be using hazardous substances when working with animals?  No  Yes (list): ______

PERSONNEL AGREEMENT Please read and initial each statement INITIAL I will perform my duties in accordance with the Animal Welfare Act, the USDA regulations, the PHS Policy on Humane Care and Use of Laboratory Animals, the current AVMA Guidelines on Euthanasia, and the current Guide for the Care and Use of Laboratory Animals I will review the protocol(s) under which I will be performing work and will be responsible for conducting this work as it is stated in the IACUC approved protocol. I will ensure that IACUC approval has been received before conducting any procedures not listed in the original protocol(s). I will immediately notify the attending veterinarian, my PI, and the IACUC when any unanticipated anima pain/distress or unexpected morbidity/mortality occurs within any of my studies.

ACC USE ONLY Initial Training Date: Topaz/Granite OHS Enrollment: Username: Profile entry date: Password: SharePoint set: Notification for EHS:

Center for Comparative Medicine / IACUC Animal Care & Use Questionnaire

Topic/ Technique Months/ Species Institution where trained (circle methods or routes) Years and approximate date Experience training was completed Handling and Restraint

Animal Identification Methods

Ear punch, Ear tag, Chip implant, tattoo, toe clip, branding Dosing

IV, IM, SC, IP, PO FP, IC Blood Collection

IV, Saphenous, RO, Tail Nick, Cardiac Puncture Anesthesia

Injectible, Inhalation Euthanasia

CO2, Cervical Dislocation, Decapitation, Injectible, Pithing (if other, name):

Aseptic Surgery Technique

Surgical Procedure

Name surgical procedure:

Surgical Procedure

ACC USE ONLY Initial Training Date: Topaz/Granite OHS Enrollment: Username: Profile entry date: Password: SharePoint set: Notification for EHS: