Form 4 Contains Following Sections; Please Complete All Applicable Section(S)

PI NAME

Form 4 contains following sections; please complete all applicable section(s).

Page 1 Drug List: (for All PIs whose protocol involves ANY KIND OF DRUGS).

Please fill out if applicable-

Page 2 Section1: drugs used for sedation, anesthesia, analgesia, or tranquilizers.
Page 3 Section 2: Use of Paralyzing agents or Neuromuscular Blocking Agents

Note1: If the protocol involves other controlled substance (such as narcotics, carcinogens, infectious agents etc), test substance, or biological, chemical, toxic, or radioactive substance, PI needs to submit Form 5: Substance Administration form.

NOTE2: If your laboratory has written Standard Operation Procedures (SOPs) of drug administration, please cite SOP #. The IACUC strongly recommends that each laboratory have IACUC approved SOPs for all experimental procedures.

1.  Provide following information:

Yes No Will you utilize drugs used for sedation, anesthesia, analgesia, or tranquilizers to animals? -If “Yes”, please also complete page 2.
Yes No Will you utilize Paralyzing or Neuromuscular Blocking Agents to animals?
-If “Yes”, please also complete page 3.

2.  Please provide the following information for drug(s) that you intend to utilize in this protocol other than sedation, anesthesia, analgesia, or tranquilizers, Paralyzing agents, Neuromuscular Blocking Agents.

Duplicate the table as often as required.

Name of Drug / Dosage
(mg/kg, %, conc.) / Volume (ml etc) / Route and
Size of Needle
(if applicable) / When and how often will it be given?
ROUTE:
NEEDLE SIZE:
ROUTE:
NEEDLE SIZE:
ROUTE:
NEEDLE SIZE:
ROUTE:
NEEDLE SIZE:
ROUTE:
NEEDLE SIZE:

NOTE: The use of expired medical materials such as drugs, fluids, or sutures on animals is not considered to be acceptable. PIs are expected to use pharmaceutical-grade medications whenever they are available, even in acute procedures. Non-Pharmaceutical-grade chemical compounds should only be used in animals after specific review and approval by the IACUC for reasons such as scientific necessity or non-availability of an acceptable veterinary or human pharmaceutical-grade product. Any compounded drugs must be prepared and administered sterile according to regulations.

Section 1: sedation, anesthesia, analgesia, or tranquilizers

Provide following information: Duplicate the table as often as required.

**If your laboratory has written Standard Operation Procedures (SOPs) for drug administration, please provide a copy along with this form. The IACUC strongly recommends that each laboratory have IACUC approved SOPs for all experimental procedures** SOP #

Name of sedation, anesthesia, analgesia, or tranquilizers / Dosage (mg/kg, %, conc.) / Volume (ml etc)
Route and size of needle / Frequency of Administration / Timing (when) of Administration
Route:
Needle Size:
Purpose of Administration
Name of sedation, anesthesia, analgesia, or tranquilizers / Dosage (mg/kg, %, conc.) / Volume (ml etc)
Route and size of needle / Frequency of Administration / Timing (when) of Administration
Route:
Needle Size:
Purpose of Administration
Name of sedation, anesthesia, analgesia, or tranquilizers / Dosage (mg/kg, %, conc.) / Volume (ml etc)
Route and size of needle / Frequency of Administration / Timing (when) of Administration
Route:
Needle Size:
Purpose of Administration
Name of sedation, anesthesia, analgesia, or tranquilizers / Dosage (mg/kg, %, conc.) / Volume (ml etc)
Route and size of needle / Frequency of Administration / Timing (when) of Administration
Route:
Needle Size:
Purpose of Administration

Section 2: Usage of Paralyzing / Neuromuscular Blocking Agents

Paralyzing / Neuromuscular-blocking Agents can conceal inadequate anesthesia and therefore require special justification. If you are using such an agent, please provide following information:

**If your laboratory has written Standard Operation Procedures (SOPs) for drug administration, please provide a copy along with this form. The IACUC strongly recommends that each laboratory have IACUC approved SOPs for all experimental procedures** SOP #

Duplicate the table as often as required.

Name of Agents / Dosage (mg/kg, %, conc.) / Volume (ml etc)
Route and Size of Needle / Frequency of Administration / Timing (when) of Administration
Route:
Needle Size:
Duration of Paralysis state

Provide detailed information below-

·  Purpose of usage of Paralyzing Agents; provide scientific justification

·  What physiological parameters are monitored during the procedure to assess adequacy of anesthesia?

·  Under what circumstances will incremental dose of anesthetics-analgesics be administered?

FORM 4 // Page 3 of 3