Division of Animal Resources Animal Request Form

Division of Animal Resources Animal Request Form

PLEASE INDICATE IN WHICH DAR ANIMAL FACILITY YOU WOULD LIKE YOUR ANIMALS HOUSED: BeckmanBurrill HallERMLIGBLACMed Sci BldgMorrill HallPsychologyRQFSentinelsSACSOLVMRFVMBSBOther (if other please explain in Section 4)

Section 1

Investigator: Ph: E-Mail:

Co-Investigator: Ph: E-Mail:

Project Title:

Animal Use Protocol #: Department/College:

C-FOAPAL #: C-FOAPAL Title:

Date Study Begins: Date Study Ends:

Have Animals Been Ordered Previously For This Project? Yes No

Section 2

Date Animals Required:Source: Animal SciencesCharles RiverCovanceEnvigo- formerly HarlanImportJackson LabsKons ScientificMarshall FarmsNascoNCINIATaconicTransferUIUC Dairy BarnUIUC Horse FarmUIUC Poultry FarmUIUC Swine FarmsVMRFWild-CaughtXenopus IXenopus ExpressOtherIf Transfer, provide protocol #:

Species: Strain/Breed/Stock #: Transgenic: Yes No

No. of Animals Required: Male Female Either/Any Available

Age or Wt. Range:

Other Requirements for Animal Order:

Will Surgical Procedures Be Performed on These Animals? Y No

Section 3

Disposition of Animals Found Ill or Injured:

Notify Investigator (Provide Phone and/or E-mail Above)

Notify Co-Investigator or Any Lab Member (Provide Phone and/or E-mail Above)

Permission for DAR Veterinary Staff to treat without prior notification

Permission to Euthanize on DAR Veterinary Recommendation and Notify Investigator Later

(Note: DAR Veterinary Staff must be notified of all cases of ill or injured animals unless illness or injury is specifically anticipated and described in an animal use protocol and animal care staff have instructions not to report these cases.)

Disposition of Animals Found Dead:

Notify Investigator (Provide Phone and/or E-mail Above)

Notify Co-Investigator or Any Lab Member (Provide Phone and/or E-mail Above)

Permission to Discard (Freeze) on DAR Veterinary Staff Recommendation and Notify Investigator Later

Save (Refrigerate) for Investigator on DAR Veterinary Recommendation

Other (Describe):

Disposition of Animals at End of Study:

Terminal Study (Animals will be Euthanized by Research or Teaching Staff)

Survival Study (Animals will Remain in Facility)

Survival Study (Animals will be Transferred To: )

Section 4

List Any Other Special Requirements Including Type of Housing, Preferred Numbers of Animals Per Cage or Enclosure, Lab Room Number, Etc.:

Section 5

Signature of PI:

(Signature of PI is not necessary for the electronic submission of this form – it should be sent by or copied to the PI to .)

DAR USE ONLY

Approved:Disapproved: Reason for Disapproval: Approved By:

Number of Animals Remaining on this Protocol: Date: Req. #:

Ordered By: Date Ordered: Delivery Date:

Amount DA00- Inv#

TOTAL NUMBER & DATE ANIMALS RECEIVED: ______