APPLICATION FOR THE USE OF CONTROLLED SUBSTANCES

IN RESEARCH NOT INVOLVING ANIMALS

Submit to the Division of Comparative Medicine

, MDC 20, ph. 974-9876, fax 974-9432

  1. TITLE OF PROJECT

2. PERSONNEL

Principal Investigator (including degrees) Position DepartmentCampus Address

Email Address Phone Technician/assistant (if applicable) Phone

  1. FUNDING SOURCE

4. LOCATION The Principal Investigator assures that this research project will be conducted in laboratories located within (describe building and room where substances will be stored, secured, and used):

5.ASSURANCE OF SECURITY PROVISIONS

All requests by University research staff for the purchase and use of controlled substances must be processed through the Division of Comparative Medicine. Use of a controlled substance in a research project requires the applicant to implement effective controls and procedures to guard against theft and misuse. Controlled substances must be stored in an area of limited access in a securely locked, substantially constructed cabinet that requires a dual-key system for entry. Use of a controlled substance requires adequate accounting of such use on forms provided by the Division of Comparative Medicine. At the completion of use of the controlled substance in a research project, completed forms and any unused or outdated substance will be returned to the Division of Comparative Medicine. Storage cabinets, logs of use, and laboratories are subject to unannounced inspections. Noncompliance can result in suspension of privileges to use scheduled substances in research.

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Signature of Principal Investigator Date

6. DESCRIPTION OF REQUESTED CONTROLLED SUBSTANCE List and describe each controlled substance requested.

Controlled substance name
Schedule number
Chemical description
Amount
Preferred Vendor

7.STATEMENT OF PURPOSE AND DESCRIPTION OF PROJECT Briefly state in lay terms the purpose (i.e., research hypothesis) of this request, and the procedures (general sequence of events) for which controlled substances will be used in research that does not involve the use of animals. Indicate how the controlled substance will be used, dosage and method of administration, if applicable, and duration of project.

8.REQUEST FOR SCHEDULE I CONTROLLED SUBSTANCES - must include a current CV and a copy of the supporting grant or contract. (Applications for use of DEA Schedule I controlled substances in research with intramural sources of funding (e.g., departmental) must be accompanied by a memorandum from the Departmental Chairperson indicating that the proposed research project is anticipated and supported.

9.I have reviewed the specific aims of the proposed research, described in item 7 (above), which involves the use of DEA controlled substance(s), am aware of its source of support, and consider this request relevant to the aims proposed.

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Signature of Department Chair Date

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Signature of Director Comparative Medicine Date

CMDC #065.6

Effective 8/15

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