REQUEST FOR ANIMAL STUDY IN THE DUKE RBL (GHRB)

* Required Fields

To be completed by Requester:

RequesterFull Name*:

Project PI*:

Project ID/Fund Code (ex 2031234)*:

Animal species*:

other (if applicable):

Anticipated number of animals in the full study*:

Desired animals per cage*:

Total number of cages requested*:

Desired STARTdate of study*:

Anticipated Length of study (days)*:

Will this experiment be repeated?* Yes NO Maybe

IF YES or Maybe* - When and how often?

Any special caging requirements (BCU cages, nest boxes, food supplements, etc.)?

Duke IACUC Number (please provide your IACUC # or indicate DUKE RBL IACUC to be used)*:

Are you IACUC approved for animal housing in the GHRB Vivarium?* Yes NO

Do you have card access to GHRB and the GHRB Vivarium?* Yes NO

Do you need additional lab members to obtain GHRB Card Access?* Yes NO

Will the study involve treatment/infection with a hazardous agent

(microbe, radiation, chemical, toxin, rDNA, viral vector etc.)?*Yes NO

IF YES*Describe the hazardous agent for the proposed study (provide as much detail about the agent/pathogen strain/construct as possible and the source for safety level assessment)*:

Duke IBC Registration (please provide your IBC# or indicate DUKE RBL Registration to be used)*:

Animal Biosafety Level*:

Do you need to make us aware of any applicable or restrictive permits/MTAs?* Yes NO

IF YES*Please describe?*

Attach/upload to the Service Request any relevant Safety or Procedure relevant to this study.

Continued on next page…

Animal Source*:

IF “Transfer to GHRB from DLAR Facility”*- Current DLAR building/room*:

- Duke IACUC Protocol #*:

- Fund Code for Perdiem*:

- Cage Numbers if applicable:

NOTE: The RBL Animal Models Coordinator will facilitate the animal Transfer with DLAR.

IF “Order from Approved Vendor”*- Vendor*:

- Strain*:

- Age*:

- Sex*: Male Female

- Fund Code for Purchase*:

- Fund Code for Perdiem*:

NOTE: The RBL Animal Models Coordinator will place the animal orders unless other arrangements are made.

Will animals be pre-treated/altered prior to arrival into the GHRB animal facility (e.g. chemical, radiation, surgery, biological)*?: (enter NA if not applicable)

What level of Animal Handling/RBL Staff Support do you need from us?*

Will you be needing any of the follow services offered by the RBL?*:

NONE

Aerobiology Exposure, Weight/Temperature Monitoring, Blood/Biosample Collections, Necropsy,

Histology/pathology, Cytokine/Chemokine Profiling, Immunophenotyping, Injections

Other

Describe Needs:

Comments/Special Instructions:

Please also Attach Supporting Documents (i.e. study plan)

to the job request in CoreResearch.duke.edu

End of requester form

To be completed by RBL Animal Models Coordinator/DHVI-RBL Safety Officer:

Are all activities covered by user or RBL IACUC Protocol? Yes NO

IF NO* - What is needed and who is submitting it?

- Date final IACUC approval verified? initials

Are all activities covered by covered by DHVI Safety SOPs? Yes NO

IF YES* - What is (are) the relevant SOPs?

IF NO* - What is needed and who is developing it?

- Date final safety approval verified? initials

Research staff access/trainingcomplete? Yes NO

IF NO* - Who needs training and on what SOPs?:

IF YES* - Date Training Review Completed:

- Date verified with DHVI safety:

GHRB Vivarium space available and scheduled: Yes NO

IF NO* - When will space be available?:

IF YES* - Study ID (investigator/species/agent/ID#):

- Assigned Safety Level:

- Study Start:

- Study End:

- GHRB Vivarium Room:

- Rack/Shelf:

- Special Handling:

DLAR notification submitted: Yes NO

IF YES* - Date Completed:Initials:

Door and cage signs created/posted: Yes NO

IF YES* - Date Completed:Initials:

Additional Comments/Notes:

gds 11/2016Page 1 of 3