Office of the
Newark IACUC
MOUSE & RAT POST-PROCEDURE MONITORING & ANIMAL USAGE FORM
**GUIDELINES**
DATE ISSUED: MARCH 12, 2013; DATE REVISED: FEBRUARY 4, 2015
GUIDELINES:
 Complete this form for all experiments involving rats and mice (Rattus and Mus species).
 This form is intended to be supplemental to laboratory notebooks (whether hardcopy or digital). This form may be
replaced with alternative documentation; however any laboratory notebooks or alternative forms must contain (at
minimum) the same information as is requested in the Main Form (page 2).
 One form is to be used for each experiment in a given IACUC protocol.
o One form can be used regardless of the number of surgeries or procedures within the experiment, as long as
differences are identified (refer to drugs & treatments below for an example).
o Enter the date the animal first entered the experimental protocol and note all of the adverse and unexpected
events and outcomes that are encountered until the animal is euthanized. If more room is needed for a given
row to record outcomes, either use the next row (if not already filled in) or use a new row and indicate it is a
continuation in the first cell(s), e.g., enter “cont. from XX/XX/XX(date)”.
o Please do not leave fields blank, instead indicate not applicable (“N/A”). Use the Continuation Sheet as needed.
 Complete the top portions (General, Procedure, Drugs & Treatments and Monitoring) for the given experiment and
add information to the Animal Usage section as animals are used. Type once, save and print as needed.
o Procedure: Briefly describe the procedures performed; include enough information to identify the procedures
and the timeframe of the experiment [e.g., aortic catheter implantation followed (3 days later) by drug delivery
every 2 days for 3 weeks].
o Drugs & Treatments: Include the name, dose and route of every drug, compound or biological material
administered to the animal – include anesthesia, analgesics, tranquilizers, euthanasia agents, test compounds,
pathogens, bacteria, viruses, cells, etc. If a non-pharmaceutical grade compound is administered to animals,
mark box accordingly and ensure compliance with CMR guidelines for preparing and storing the compound.
o
DRUGS & TREATMENTS
Indicate name(s), dose(s), frequency, duration, and route of all drugs, treatments & test agents administered:
Pre-OP: Catheter: cephazolin (60 mg/kg, IP) – once. Terminal: none.
Anesthesia: Catheter: Ketamine/Xylazine (5-10/60-80 mg/kg, IM) – once and then XXX as needed. Terminal: penotbarbitol (50 mg/kg, IP)
Post-OP: Buprenorphine (0.06 mg/kg, SC) – once
Treatments & Test Agents: dexamethasone (0.1 mg/kg, SC) – one dose every 2 days for 3 weeks.
Will non-pharmaceutical grade compounds be used in this experiment?
MONITORI
NG
o
YES
NO
Monitoring: An example of an entry into the Monitoring section
Briefly describe monitoring procedures (prior to, during and after experimentation): Animals will be visually inspected to ensure they are not ill.
Once anesthetized (confirmed via absence of a response to foot pinch (checked every 5 min)), animals will be intubated and ventilated with a tidal
volume of 0.2 ml and a respiratory rate of 110 breaths per minute (respiratory rate and depth checked every 5 min). Upon recovery, animals will be
returned to home cage and checked regularly until it is fully ambulatory and then daily until euthanized.

Complete the bottom portion (Animal Usage) on the day when the animal(s) first enter the experimental protocol and note
all of the adverse and unexpected events and outcomes (on the day of their occurrence or when they are first noticed that
are encountered) until the animal is euthanized. If more room is needed for a given row to record outcomes, either use
the next row (if not already filled in) or use a new row and indicate it is a continuation in the first cell(s), e.g., enter “cont.
from XX/XX/XX(date)”.
MOUSE & RAT POST-PROCEDURE MONITORING & ANIMAL USAGE FORM
**MAIN FORM** PAGE __ OF __
Office of the Newark IACUC
DATE ISSUED: MARCH 12, 2013; DATE REVISED: FEBRUARY 4, 2015
Investigator (PI):
Protocol number &
species:
Protocol experiment #
& pain category:
Brief description of procedures performed:
Experimenter name(s):
Animal procedure
room number(s):
Corresponding lab
notebook ID(‘s):
PROCEDURE
S
GENERAL
Refer to Guidelines for form completion. All procedures must be performed as described in the approved IACUC protocol.
DRUGS & TREATMENTS
Indicate name(s), dose(s), frequency, duration, and route of all drugs, treatments & test agents administered:
Pre-OP:
Anesthesia during procedure:
Post-OP:
Treatments & test agents:
MONITORING
Will non-pharmaceutical grade compounds be used in this experiment?
NO
Briefly describe monitoring procedures (prior to, during and after experimentation):
Date
ANIMAL USAGE
YES
# of
animals
Adverse or
unexpected events
or outcomes? Y/N
If yes, briefly describe (include animal ID(s) and corrective
action(s) taken and/or endpoint):
MOUSE & RAT POST-PROCEDURE MONITORING & ANIMAL USAGE FORM
**CONTINUATION SHEET** PAGE __ OF __
Office of the Newark IACUC
DATE ISSUED: MARCH 12, 2013; DATE REVISED: FEBRUARY 4, 2015
GENERAL
Refer to Guidelines for form completion. All procedures must be performed as described in the approved IACUC protocol.
Investigator (PI):
Protocol Number &
Species:
Protocol Experiment #
& Pain Category:
ANIMAL USAGE
Date
# of
animals
Experimenter name(s):
Animal Procedure
Room Number(s):
Corresponding Lab
Notebook ID(‘s):
Adverse or
unexpected events
or outcomes? Y/N
If yes, briefly describe (include animal ID(s) and corrective
action(s) taken and/or endpoint):