IDENTIFICATION

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IDENTIFICATION Powered By Docstoc
					Animal Use Qualifications Documentation Form                              Date _______________                       Q # ____________________

DO NOT USE THE TAB KEY ON PAGE 1 – MOVE YOUR CURSOR.                                                New Form                        Revised Form

IDENTIFICATION                                                                    EDUCATION
Name                                Supervisor’s Name                             Degree               Institution                                   Year
Dept/Unit                    Bldg               Phone                             Degree               Institution                                   Year
Email                                                                             Degree               Institution                                   Year

 Animal Caretaker                Staff/Technician                                 Laboratory Animal or Veterinary
 Undergraduate                   Graduate Student                                 Certifications/Diplomates/Licensures/Specialties
 Post-Doc                        Resident/Intern
 Faculty                         Visiting Staff/Technician*
                                                                                  INSTRUCTION BY LABORATORY ANIMAL PROGRAM
*Address if a Visiting Staff/Technician                                           Species         Technique



SPECIAL TRAINING include statistics & experimental design                         Do you know how to report deficiencies/concerns regarding animal
                                                                                  care and use? Yes             No
Year taken:                                                                       www.purdue.edu/research/vpr/rschadmin/rschoversight/animals/policies.php
Course:
                                                                              For links in Blue, press the CTRL key + left CLICK mouse.
Have you been informed of:
1. Purdue’s occupational health and safety program?            Yes   No     N/A           www.purdue.edu/research/vpr/rschadmin/rschoversight/animals/occhealth.php
2. REM’s requirements for handling controlled substances?      Yes   No     N/A           www.purdue.edu/rem/eh/DEA.htm
3. Purdue’s program of veterinary care?                        Yes   No     N/A           www.purdue.edu/research/vpr/rschadmin/rschoversight/animals/docs/vetcare2.pdf
4. How to obtain veterinary care?                              Yes   No     N/A           www.purdue.edu/research/vpr/rschadmin/rschoversight/animals/vetcare.php
5. Purdue’s policy on required medical record keeping?         Yes   No     N/A           www.purdue.edu/research/vpr/rschadmin/rschoversight/animals/forms/policy2.pdf
6. USDA’s policy on handling of expired medical materials?     Yes   No     N/A           http://www.aphis.usda.gov/animal_welfare/downloads/policy/policy3.pdf
7. USDA’s policy on handling pharmaceutical-grade compounds?   Yes   No     N/A           http://www.aphis.usda.gov/animal_welfare/downloads/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 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 03/10
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 protocol to which you are assigned.

Species          Husbandry      Handling/    Breeding    Nutrition    Blood       Injections    Oral      Anesthesia     Aseptic    Post-     Euthanasia
                                Restraint                            Collection                Gavage     Analgesia      Surgery     op
                                                                                                                                    Care
Amphibian
Bird (Wild)
Cat
Cattle
Dog
Fish
Gerbil
Guinea Pig
Hamster
Horse
Mouse
Poultry
Rabbit
Rat
Reptile
Sheep/Goat
Swine
Other:
Other:

SPECIFIC PROTOCOL RELATED EXPERIENCE (pre-operative, surgery, post-operative)
Technique/procedure                                                                      Species used           Years performed      Faculty Initials




Your signature ________________________________ Supervisor’s name & Signature ___________________________________
                                                                                                                                        Q-form Revised 03/10

				
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