University of Connecticut
Appendix D: Use of Hazardous Agents or Controlled Substances
Institutional Animal Care and Use Committee, Office of Research Compliance
Whetten Graduate Center, Rm #214, 438 Whitney Road Ext., Unit 1246 Storrs, CT 06269-1246 860-486-8802
Office Use Only
IACUC Protocol #_____________
Approval Date: ______________
Expiration Date: _____________
Species_____________________
Guide exceptions: Y__N__
Hazards: Y__ N__
Instructions: This form is a companion to Section XI of the Protocol for Animal Care and Use
(IACUC-1) Form. The completion and submission of this form is required, as described in the
aforementioned section, under the following circumstances:
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Research objectives require the use of radioisotopes, lasers, x-rays
You are using an experimental compound with unknown toxicity
The objectives of your project require the use of hazardous or toxic chemicals in animals
You are utilizing recombinant DNA/RNA or transgenic animals
The experimental design includes the use of material of human origin or human, animal or plant pathogens
Section I: PI (Principal Investigator) and Protocol Information
Principal Investigator (PI):
Project title:
Section II: Providers of Care: Who will potentially be exposed to hazards on this protocol (include waste handling)? Check all that apply:
Animal Care Services (ACS) Staff
Agricultural animal care staff
Principal Investigator (PI) and/or research staff
Students under the direction/ instruction of the PI
Section III: Hazardous agents to be used: Please complete the table below to indicate which hazardous agents will be used under this protocol.
Agent/Material
Check all
that
apply
Specify agent or material
Species of animal to
be exposed to
Agent/material
Approximate
number of animals
to be exposed to
agent/material
Radioisotopes
Recombinant DNA/RNA
Human, Plant or Animal Pathogen
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Human Material (cells, tissues, organs, body
fluids)
Toxic Chemicals
Experimental Chemicals and Chemotherapeutics
(including carcinogens/mutagens/teratogens)
Experimental Drugs (i.e., controlled substances)
Other
Section IV: Specific questions regarding hazardous agents
A. If human or animal pathogen or material of human or animal origin, designate the Biosafety Level: BSL____
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B. Describe any engineering controls, administrative controls and personal protective equipment utilized to mitigate the risk associated
with this agent/material. Attach additional documentation (e.g., a separate safety manual) if needed.
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C. Describe the experimental procedures, including specifics of the hazardous agent(s)/material to be used, dose, route of
administration, frequency of application, length of exposure and route of excretion.
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D. Describe any potential health risks to animals and/or humans.
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E. Describe any special animal care and use requirements.
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F. When the hazard is present, where will the animals be housed and where will they be used during this time?
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G. Describe any special postings on animal or laboratory room doors, cages, etc. Submit copies of any signs to be used with this form.
Contact Biosafety for posting of Biohazard signage.
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H. When the hazard is present, who will care for the animals and who will use the animals?
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I.
For animal care staff and others using live animals or exposed to soiled equipment, describe any special precautions that will need to
be taken
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J. Who will instruct the animal care staff and others working with these animals or with soiled equipment used with these animals?
Describe this person’s training and experience with the hazard.
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K. Describe special containment facility requirements e.g., procedures necessary to protect other animals in the room, in the facility,
and/or in the environment; e.g., provide the name of the disinfectant and the procedure used for decontamination, foot baths, pest
control, etc.
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L. Describe bedding and animal disposal requirements.
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M. What is the procedure in the event of an emergency?
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N. Additional information (To be filled out upon request):
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