ANIMAL ORDER FORM

                                                            

                                                                                                                      DATE:____________________

 

MASTER ORDER #_____________________________ VENDOR_____________________________

             

 

Principle Investigator’s Name**_____________________________________Ext.________

Department_____________________________________________________________ 

 

PROTOCOL NUMBER ______________

TITLE (Required by IACUC) ___________________________________________________ __________________________________________________________________________________________________________________________________________________________

Animals Required (Please specify Sex, Weight, Strain, etc.)

_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________

·              Biohazards (radioisotopes, chemical toxins, infectious agents, etc.)      ‚  YES        ‚   NO

SPECIFIC INSTRUCTIONS:

·              Check  specific instructions  below that are required for this order.  List any additional requirements.

€              Feeding Requirements ___________________________________________________________

€              Watering Requirements____________________________________________________________

€              Light Cycle Requirements_________________________________________________________

€              # of animals per cage ______

€              Type of Caging:  Metabolic Rack___ Shoe Box___, Other  (Specify)  _________

€              Type of Diet:    Standard ____   Investigator Supplied ____

€                     Additional Cage Cards Needed:  ________

€                     Additional Requirements not listed above_______________________________

Date Delivery Required ____________________________________________________

                                                                                                                       

                                                                        Responsible Investigator

 

For LAF Office Use Only:

   Facility Manger/Facility Supervisor Approval         ____________________            Date:__________________

€   HOLD                                                                          (Approver’s Initials)

   Location to be housed     Rm#_______________         # of Cages Needed   _____     # Animals  housed per cage: _______                    

      Bldg:  (  )  Guyton  Building

                 (  )  Animal Facilities – 8th Floor Research                        TOTAL # CAGE CARDS NEEDED________

                 (  )  Animal Facilities – Clinical Sciences Building           

                 (  )   Departmental Animal Room # _____________

·    Date Ordered________________________________       Order Called in by____________________________

·    Order Confirmed with_________________________       Delivery Date:_______________________________

·    Reference #__________________________________      Confirmed Price:  ____________________________

 

 

 

Revised:  9/11/00 word/Animal Order Form. doc