this form on the lab/animal room door two weeks prior to start of protocol. / Date last revised: Date Posted:
Department: / Protocol #:
Room: / Building:
Authorized Personnel
/ Campus Phone / Home Phone / Pager/MobilePrincipal Investigator:
Authorized Personnel:
Authorized Personnel:
Precautions for this protocol (for assistance, contact OEH&S and/or DLAR)
Animal Species:Type of Hazard
Biohazardous Agents:
Check category and list agent(s) / [ ] BSL 1:
[ ] BSL 2:
[ ] human cell lines or human tumors*:
Location of Biosafety Cabinet
Chemical Agents (including gas anesthetics)**: / BrdU
Radioisotopes**:
How long should precautions be followed?
(Note: You must notify DLAR each time these precautions should be instituted) / [ ] 72 hours
[ ] Duration of project
[X] Other_7 days______
Protective Clothing: / [x] gloves [ ] dust mask [X] N95 respirator
[ ] foot covers [ ] head cover/ bonnet [x] safety glasses
[ ] goggles [x] sleeves (while working in biological safety cabinet)
[x] for lab/ research staff: gown or lab coat
[x] other: recommend lab coat or disposable gown for DLAR staff
Route of Animal Excretion: / [x] urine [x] feces [ ] saliva
[ ] respiratory [ ] none expected
[ ] other:______
Animal Carcass Disposal: / [x] routine incineration [x] chemical waste
[ ] biohazardous waste [ ] radioactive waste
[x] other: *chemical hazard carcasses are to be placed in tagged waste containers, frozen and stored for disposal by OEHS, see comments below
Biohazardous Caging/Bedding Disposal: / [ ] regular waste
[ ] autoclave then treat as regular waste
Chemical or Radioactive Caging/Bedding Disposal: / Bedding:
[ ] regular waste [x] chemical waste
[ ] radioactive decay [ ] radioactive waste
Caging:
[ ] regular waste
[x] autoclave then treat as regular waste
Surface and Equipment Decontamination [ ] radioactive decay [ ] other: ______/ [ ] autoclave [ ] bleach [ ] Spor-Klenz
[ ] quat. ammonia compound [x] regular cage wash procedure
[ ] any of the above marked options
Note: avoid using bleach on stainless steel surfaces (biosafety cabinets)
Animal Handling Precautions: / [ ] room pressurization negative to corridor
[x] biological safety cabinet used for cage changes and animal handling (req. for BSL 2)
Additional Precautions: (e.g.: immunizations, restricted access, special decontamination, specific waste disposal, etc.) / BrdU may be harmful if inhaled, absorbed through the skin or swallowed. Suspected of causing genetic defects. Suspected of causing cancer. Suspected of damaging fertility of the unborn child.
**NOTE: Individual cages must be identified with the hazardous agent, date of administration and appropriate hazard label.
1. My staff and I will comply with all standards for animal care and investigation established in the Guide for the Care and Use of Laboratory Animals and the Federal Animal Welfare Act, and will follow all policies established by the University to assure that these standards are met.
2. I assume responsibility for the work described here.
3. All individuals working with the animals on this protocol are qualified by virtue of training or experience to perform proper handling, experimental, and restraint techniques required for the species to be used.
4. I recognize my responsibility to identify occupational health hazards related to this protocol including identifying hazards, providing the necessary training for those involved, and supplying the appropriate protective clothing and equipment to minimize the risks.
5. This research does not represent unnecessary duplication of previous experiments.
6. I realize that failure to adhere to policies related to animal care and use may result in suspension or revocation of permission to perform animal research in Wayne State University facilities.
7. For more information please read the safety standard operation procedures (SOPs). The PI and OEHS will maintain a copy of the SOPs.
Signature of Principal Investigator
(must be original; no copies, image files, etc.) / Date
Approval Date (to be filled in by OEH&S):