UNIVERSITY OF COLORADODENVER

PERSONNEL QUALIFICATIONS TO PERFORM ANIMAL RESEARCH

Please complete one form for EACH INDIVIDUAL named on the protocol. MUST BE TYPED.

Pleasesave as 'Word' File for Future Reference.

EMPLOYEE NAME(Exactly as in UC Denver records)
UCDenverEMPLOYEE NUMBER (not SSN) / EMPLOYEE E-MAIL ADDRESS(work only) / MAIL STOP / PHONE (work, not cell):
ANIMAL USE LOCATION (lab) / DEPARTMENT AFFILIATION
PRINCIPAL INVESTIGATOR / PI E-MAIL ADDRESS (work only) / MAIL STOP / PHONE (work, not cell):
PROTOCOL NUMBER(S) FOR PROTOCOLS WITH WHICH THIS EMPLOYEE IS ASSOCIATED (or “new submission” or “reference #”for new protocol)
(use a separate PQ for associates listed on several protocols for different PIs)

Responsibilities under Protocol # :

(Please list the procedures to be conducted under each protocol listed, e.g. ip injections, CO2 euthanasia, oral gavage. Protocol numberalone is not sufficient.)

Authorized to Order Animals under Protocol #:

(Please indicate if associate is authorized to order animals under each protocol listed)

I perform no animal procedures or manipulations (this refers to personnel who never handle animals)

FORMAL EDUCATION AND / TRAINING:
Degree(s) Earned (s): / Date(s): / Institution:
Certifications:
AALAS /Vet Tech / Specify:
Other / Specify:
COURSEWORK RELATED TO ANIMAL CARE & USE:
UC Denver Courses / RPL1 Training: Basic Techniques in RodentsDate:
RPL2 Training: AsepticSurgical Techniques and SuturingDate:
Other / Specify:
OCCUPATIONAL HEALTH (CHECK THE APPROPRIATE STATEMENT): See the Web Site for Program Requirements and Details
I have enrolled/ will enroll in the Occupational Health Certification Program. Date:
I have completed my annual update of the Occupational Health Certification Program. Date of Annual Update:
I perform no animal procedures or manipulations.

NAME: ______

Describe your experience with procedures on live animals, or your plans for training. Please attach additional sheets as needed. Please specify Mice, Rats or Both by bolding or circling the appropriate species. Please specify Other Species as necessary.

Procedure / Species / Method / Route / # Years of Experience
Or “in training” / Training: By Whom/How
Anesthesia
(e.gInhaled, Injected, etc.) / Mice/Rats
Other (specify):
Blood Collection
(e.g. IV, Tail Vein, Intracardiac, etc.) / Mice / Rats
Other (specify):
Euthanasia

(e.g. CO2, injected, etc.)

/ Mice / Rats
Other (specify):
Restraint and Handling
(List Devices/Methods in Method Column, e.g. Manual, restrainer, etc.) / Mice / Rats
Other (specify):
Animal ID (e.g. ear punch, microchip, tattoo, etc.) / Mice / Rats
Other (specify):
Administering Injections
(e.g. IV, IP, SC, etc.) / Mice/Rats
Other (specify):
Sterile Surgery (List Specific Procedures in Method Column) / Mice/Rats
Other (specify):
Non-sterile Surgery (List Specific Procedures in Method Column ) / Mice/Rats
Other (specify):
Gavage / Specify:
Other (Describe Procedure in the Methods Columne.g. necropsy, tissue collection) / Mice/Rats
Other (specify):
I certify that I am qualified to perform the procedures listed, or if not currently qualified, I will get appropriate training and become competent in the procedures before I perform them on live animals.
Employee Signature (not typed)
Date / I certify that I will ensure the above individual is competent with the procedures before allowing him/her to perform these manipulations on live animals.
______
Principal Investigator's Signature (not typed)
______Date

Please e-mail signed, scanned copy to the IACUC email address .

Rev 01/16