PI NAME

Form 5; please complete all applicable section(s).

Note1: For usage of sedation, anesthesia, analgesia, tranquilizer, or paralyzing/neuromuscular block agents, please fill out FORM4 Drug Administration.

NOTE2: **If your laboratory has written Standard Operation Procedures (SOPs) for biological toxin and/or controlled substance administration, please cite SOP #. The IACUC strongly recommends that each laboratory have IACUC approved SOPs for all experimental procedures.

NOTE3: Contact Office of Environmental Health and Safety for biological toxin use. Please note that usage of biological toxins may require IBC approval.

Office of Environmental Health and Safety

Chemistry B73

Phone: (518)-442-3495 Fax: (518)-442-3783

  1. Provide following information:

Which substance(s) will be used in this protocol?

Biological Toxin Radionuclide Hazardous Chemical/drug (specify: )

Narcotics Carcinogens Other controlled substance (specify: )

Test Substance (specify: )

Other (specify: )

NOTE: Appropriate licenses or certifications may be necessary for the use of all these substances. Also you MUST contact the Environmental Health and Safety office for the use of drugs/chemicals.

NOTE: If you utilize, Chemical, Toxic or Radioactive Substances, you must have approval from the appropriate University at Albany (Bio-safety, Radiation Safety) committees.

  1. Please provide the name of personnel who will be responsible for purchasing, holding, keeping, and safely managing substances.

NAME / QUALIFICATION
Faculty Postdoctoral Graduate
Undergraduate Other:
  1. Please provide a list of personnel includingall staff whowill physically handle all substanceslisted above and who is conceivably at risk from research procedures involving the use of these substance(s).

NAME / QUALIFICATION
Faculty Postdoctoral Graduate
Undergraduate Other:
Faculty Postdoctoral Graduate
Undergraduate Other:
Faculty Postdoctoral Graduate
Undergraduate Other:
  1. Provide following information: if you have IACUC approved SOPs, please cite SOP number

Yes No Do the chemical will be used in this protocol involved present a special health risk to human or animals?

(if YES, explain:)

Yes No Will the animals be anesthetized or sedated when these agents are administered?

(if YES, explain:)

Yes No Is this agent shed in urine, feces, and/or other bodily secretions?

If Yes, provide following information.

-By what route is the agent shed?

-How long after inoculation will the viable, infectious agent be shed?

-Describe how animal bedding and carcasses will be disposed of.

  1. Describe following procedures
  • Describe how the staff listed in page 1 have been or will be informed of the possible risks of exposure, and what training they will received on how to handle these agents
  • Describe the procedures to be followed in the event of a spill or release of agents that will be used.
  • Describe the emergency contact procedures that will be used.
  1. Provide following information; Duplicate the table as often as required.

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

FORM 5 // Page 1 of 2