Please Type Or Print All Information Clearly and Completely

PLEASE TYPE OR PRINT ALL INFORMATION CLEARLY AND COMPLETELY

Animal Use Qualifications Documentation Form Date ______Q # ______

New Form Revised Form Date:

NOTE: Please read the instructions and complete the back of this form before returning to the PACUC office (VAHF).

Q-form Revised 10/05

PLEASE TYPE OR PRINT ALL INFORMATION CLEARLY AND COMPLETELY

Animal Use Qualifications Documentation Form Date ______Q # ______

IDENTIFICATION

Name Supervisor’s Name

Dept/Unit ADDLANSCBCHMBIOLBMEBMSCHEMCPRENTMFSCIF/NFNRHSCIHSRCIPPHMCMPMed EdPSYCS/AVADVCSVLACVPBVTHN/A Bldg ADDLBCHMBRWNCALCIVLENTMFORSFSFTWHANSLILYLYNNNCENPOTRPOULPRCEPSYCRHPHSMTHSTONVAHFVCPRVPTHWTHRN/A Phone

Email

Animal Caretaker Staff/Technician

Undergraduate Graduate Student

Post-Doc Resident/Intern

Faculty Visiting Staff/Technician*

*Address if a Visiting Staff/Technician

SPECIAL TRAINING include statistics & experimental design

Year takenCourse

EDUCATION

Degree Institution Year

Degree Institution Year

Degree Institution Year

Laboratory Animal or Veterinary

Certifications/Diplomates/Licensures/Specialties

INSTRUCTION BY LABORATORY ANIMAL PROGRAM

SpeciesTechnique

Do you know how to report deficiencies/concerns regarding animal care and use? Yes No

Whistle blowing policy

NOTE: Please read the instructions and complete the back of this form before returning to the PACUC office (VAHF).

Q-form Revised 10/05

PLEASE TYPE OR PRINT ALL INFORMATION CLEARLY AND COMPLETELY

Animal Use Qualifications Documentation Form Date ______Q # ______

Have you been informed of:

1. Purdue’s occupational health and safety program? Yes No N/AOccupational Health Program

2. REM’s requirements for handling controlled substances? Yes No N/Ahttp://www.purdue.edu/rem/eh/DEA.htm

3. Purdue’s program of veterinary care? Yes No N/AVeterinary Care Program

4. How to obtain veterinary care? Yes No N/AHow to obtain veterinary care

5. Purdue’s policy on required medical record keeping? Yes No N/AMedical Record Keeping Policy

6. USDA’s policy on handling of expired medical materials? Yes No N/Ahttp://www.aphis.usda.gov/ac/policy/policy3.pdf

7. USDA’s policy on handling pharmaceutical-grade compounds? Yes No N/Ahttp://www.aphis.usda.gov/ac/policy/policy3.pdf

As a Principal Investigator (faculty/staff member) do you know how to use electronic databases (e.g. MedLine, National Library of Medicine / National Agricultural Library) http://altweb.jhsph.edu/searchalt.htm OR http://www.nal.usda.gov/awic/alternatives/alternat.htm

1. To determine alternatives to animal use Yes No

2. To refine, reduce, replace animal use Yes No

NOTE: Please read the instructions and complete the back of this form before returning to the PACUC office (VAHF).

Q-form Revised 10/05

Complete the following chart by inserting the date the applicant completed training for each task. Each task must be certified and initialed in each box by the area supervisor or faculty member. Only full-time faculty and principal investigators may provide their own authorization. Only complete the boxes that are related to the tasks you will be performing on the research protocol to which you are assigned.

SPECIFIC PROTOCOL RELATED EXPERIENCE (pre-operative, surgery, post-operative)

Your signature ______Supervisor’s name & Signature ______

Q-form Revised 10/05