REQUEST FOR TECHNICAL ASSISTANCE or SERVICE
Department of Com parative Medicine
Requests for technical assistance or services from the DCM or to schedule the use of the DCM experimental surgery or radiology facilities
must be in writing and signed by the Principal Investigator or authorized assistant. Deliver the completed form to the Department of
Comparative Medicine, 992 MSB as far in advance as possible. The form may be faxed to the DCM @ 460-7783.
Complete the following information:
Date
Principa l Investigato r
Protoc ol #
(Please print)
Tele phone num ber
Pager/Cell Phone Number
Species
Anima l/Cage ID#
Room #
Date and Time for Requested Service
am/pm
Check appropriate items below and provide descriptive information where requested (attach additional sheets if required):
G
G
G
G
Adm inister medications
Anesthetize
(m edic ation, dos e, rou te, fre que ncy) :
(agent, dose [per protocol]) :
Deliver to (building and room#) :
Co llect fluids or m aterials
 ascites fluid
 blood
 feces
 urine

G
Euthanatize
ml
9 No anticoagulant
ml
9 Anticoagulant (type &
qua ntity)
gm
ml
ml
(ag en t, m eth od [p er p rotocol]
 Save and notify when completed
9 Re frigerate
9 Freeze
 Disc ard
G
Fast an ima l(s):
 Ov ernight
 24 hou rs

(12-16 hours)
No food No water
No food or water
9
9
9
9
9
9
9
9
9
NO
YES ( Type and d osage
(requires approval by clinical veterinary staff)
(may requ ire approval by clinical veterinary staff)
G
G
G
G
Pre-medication required?
G
G
Surgical procedure (to
G
Calendar schedule is attached for multiple procedure request covering an extended period of time.
)
Complete reverse side: Request to Schedule Experimental Surgery or Radiology Facilities
Radiology procedures
Recovery pen/cage required? NO
Restraint/manipulation
YES
(describe)
be performed in DCM)
Complete reverse side: Request to Schedule Experimental Surgery or Radiology Facilities
Other
Sign atur e of P rinc ipal I nve stiga tor o r Au thor ized Ass istan t REQUIRED
(1/98)
REQUEST TO SCH EDULE EXPERIM ENTAL SURGERY or RADIOLOGY FAC ILITIES
Department of Comparative Medicine
Please check appropriate item(s) below and provide descriptive information as requested.
G SURGERY
Location
F Acute Surgery Facility [Non-survival procedure]
F Aseptic Surgery Facility [Survival procedure (requires completed POST-PROCEDURE CARE RECORD)]
F Aseptic Surgery Facility [Survival, multiple procedure (requires specific IACUC approval & completed POST-PROCEDURE CARE RECORD)]
Procedures to be carried out
F Thoracic:
describe procedures:
F Abdominal:
describe procedures:
F Other :
describe procedures:
Anesthesia
Type, dose and route of administration:
Administered by
F DCM personnel
Is ventilation required? F Yes
F No
F Research personnel (identify):
Anticipated duration of surgery:
Animal surgical prep & positioning
F Standard surgical prep F by DCM personnel F by research personnel/investigator
F Animal position:
Elevation
“ Flat
“ Head elevated
“ Head lowered
“
Instrument pack
F Major
F Cut-down
F Dental
Position
“ Dorsal exposure
“ Ventral exposure
“ Lateral exposure
 right side
 left side
“
Medical Gases
F Air
F Nitrogen
F Nitrous oxide
F Necropsy
F
F
Monitoring equipment (Note: not all equipment may be available)
F Respiration
F Pulse Oximeter
F Temperature
F ECG
F Blood Pressure
F Other
General Equipment
F Cautery
F Suction
F Gas anesthesia
F Heating pads
F IV administration setup
F Operating microscope
Parenteral Fluids
Type
Type
Type
F Oxygen
F
F
Dose/Rate
Dose/Rate
Dose/Rate
F
F
F
G RADIOLOGY
Area to be radiographed:
Animal position
F AP
F Lateral
F Oblique
F Other
Contrast media YES
Type
Route
# of exposures required:
Special procedures
Specify:
NO
Route
Route
Route