INSTITUTIONAL ANIMAL CARE AND USE COMMITTEE
PERSONNEL FORM
PROTOCOL INFORMATION
Study Title
Project Director
Phone #
PERSONNEL INFORMATION
Name
Phone #
☐ Faculty
☐ Staff
☐ Undergraduate Student
☐ Other:
Email
☐ Post Doc
Will this person be an emergency contact for this project?
☐ YES
☐ Graduate Student
☐ NO
ONLINE TRAINING
☐
Working with the IACUC
☐ NA
Click here to enter a date.
☐
Working with Amphibians in Research Settings
☐ NA
Click here to enter a date.
☐
Working with Fish in Research Settings
☐ NA
Click here to enter a date.
☐
Working with Mice in Research Settings
☐ NA
Click here to enter a date.
☐
Working with Rats in Research Settings
☐ NA
Click here to enter a date.
☐
Wildlife Research
☐ NA
Click here to enter a date.
☐
Aseptic Surgery
☐ NA
Click here to enter a date.
☐
Post-Procedure Care of Rats and Mice: Minimizing Pain and
Distress
☐ NA
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☐
Post-Approval Monitoring (PAM)
☐ NA
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☐
Chemical Safety
☐ NA
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Personnel Form
Amended: 10.22.2015
Page 1 of 2
Protocol Title:
INDICATE ALL TASKS TO BE PERFORMED BY THIS INDIVIDUAL
☐
Husbandry
☐
Non-Surgical Procedure(s)
☐
Anesthesia
☐
Surgery
☐
Surgical Assistance
☐
Catheterization
☐
Instrumentation
☐
Sample Collection
☐
Euthanasia
Other – Describe:
YEARS OF EXPERIENCE (for work specific to this protocol)
With this species
With procedure(s)
With survival surgery (If applicable)
Who has or will provide training?*
Procedure
Name of Trainer
* Training can be listed as “N/A – Trained and Experienced” (this question only applies to the procedures described in this protocol).
Personnel Form
Amended: 10.22.2015
Page 2 of 2