The University of Western Ontario - DOC by jd95Sb


									                          The University of Western Ontario
Health Sciences Animal Facility Card Access Request Form
          Please print, complete, authorize, then send form to ACVS, Rm. 510, MSB - fax 661-2028
                                   Today’s Date: dd/mm/yy               /          /
Protocol Information: Card access will proceed only when your name has been added to your supervisor’s protocol(s).
                            List all protocol numbers you are currently involved with:

Originating Department:
      Department:                        Supervisor:           Supervisor Contact #:            Supervisor Signature:

Cardholder Information:
  Surname: Last Name           Given Name: First Name               Email Address:                 Work Contact #:

Home Address:                                                      Campus Address:              After Hours Contact #:

Employment Status:
                          Pick One                               If Staff, Pick One              If Student, Pick One
                                                             Full-time Part- time              Graduate   Summer
             Faculty /     Staff    /   Student
                                                             Temporary Post-Doc                Undergraduate
Card Access Requirements:
                        Area Access Requested: Circle All Required
                   Exclusion            Inclusion       Interior                              Sheep          Other:
   General                                                                   NHP
                    Barrier              Barrier        Barrier                             6050/6015
                                                  Time Requirements:
          Days of the Week: Pick Required                                              Time: Pick One
  Monday to Friday / Weekends & Holidays                      7 a.m.- 6 p.m. / 7 a.m. – midnight / 24 hours
 *Facility Manager approval is required prior to authorization of access request beyond 7 a.m. – 6 p.m. weekdays.
                       Please provide an explanation for extended hours requested below:

                                         ACVS OFFICE USE ONLY
Facility Manager Name              Manager’s Signature                      Date                Protocol Confirmation

Area Training Record:
          Area                          Training Date                       Area                    Training Date
    HS General Facility                                               Primate Unit
     Exclusion Barrier                                             Containment Barrier
     Inclusion Barrier                                              Sheep 6050 Suite
         Level III                                                  Sheep 6015 O/R
Other Training:
       Sheep SOPs                                                      Primate SOPs
    Sheep Staff Health                                             Primate Staff Health
      Sheep OH&S                                                      Primate OH&S
Card Details:
          Card #                            PIN #                                  Card Cancellation Date

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