Animal Care / Use Application
Appendix C
ORC Use Only:
Protocol #:
Approval:
Surgery (Survival and Non-Survival)
Form completion instructions: To populate a box, click once on the box to show the “X.” To uncheck box, click on it once more to remove “X.” For
narrative responses, click on the prompt text (“Click here to enter text”) and begin typing.
Protocol Title: Click here to enter text.
Principal Investigator: Name: Click here to enter text.
Department: Click here to enter text.
Instructions: Please only complete applicable section(s) – Section 1 is survival surgery and Section 2 is non-survival surgery. NOTE: Please consult
the Rodent Surgery Policy prior to completing your responses below (if applicable).
Section 1: Survival Surgery
☐ N/A
NOTE: Survival surgeries are only to be performed in the Vivarium.
1.
Survival Surgery (Single and Multiple)
a. Will any of the animals have undergone prior survival surgery by the vendor or under a different
protocol?
☐ No. Animals will not have had prior surgery
☐ Yes. Animals will have had prior surgery.
If YES, provide a listing of prior surgeries (include dates):
Click here to enter text.
b. Will any animals experience more than one survival surgery, including surgery prior to entering the
study?
☐ No. Animals will have only one survival surgery.
☐ Yes. Animals will have had more than one survival surgery.
If YES, provide scientific justification why multiple surgeries are necessary to achieve the scientific
objective:
Click here to enter text.
c. Provide a description of surgery(ies) to be performed, including anatomy and organs involved,
location and size of incisions, method and materials for wound closure, and description of implanted
materials/devices.
Click here to enter text.
2.
Pre-Operative Animal Support (not anesthesia): Specify pre-operative actions taken to prepare the animals
for survival surgery (select all that apply):
☐ Physical exam
Appendix C: Surgery
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☐ Overnight food withdrawal
☐ Body temperature support
☐ Clipping of fur
☐ Ophthalmic ointment to eyes
☐ Chlorhexidine + alcohol scrub
☐ Fluids (list)
Click here to enter text. OR
☐ Other:
Click here to enter text.
3. Pre-Operative Anesthesia/Analgesia: Will pre-operative anesthesia/analgesia be provided to animals?
☐ No. Drugs will not be administered to the animals prior to surgical anesthesia
☐ Yes. Pre-operative drugs will be used.
If YES, complete table below. Select the Drug Name from the drop-down list.
Note on drop down lists: Choose only one item per row. To unselect an option simply click on “Choose an item.”
Complete other cell entry in the table by typing in information.
Drug Name
Dose
Route
Frequency of
Administration
Anticipated
Duration of
Effect
Choose an item.
Click here to
enter text.
Click here to Click here to enter
enter text.
text.
Click here to
enter text.
Choose an item.
Click here to
enter text.
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enter text.
text.
Click here to
enter text.
4. Paralytics Use:
a. Will paralytics be used at any time during the surgery?
☐ No. Paralytics will not be used.
☐ Yes. Paralytics will be used.
If YES, complete table below.
Route
Frequency of
Administration
Anticipated
Duration of
Effect
Drug Name
Dose
Click here to enter
text.
Click here to
enter text.
Click here to Click here to enter
enter text.
text.
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enter text.
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text.
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enter text.
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enter text.
text.
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enter text.
b. If Paralytics will be used, provide justification for their use:
Click here to enter text.
5.
Intra-Operative Animal Support: Specify intra-operative care that will be provided to animals during survival
surgery (select all that apply):
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☐ Mechanical ventilation
☐ Intravenous fluids
☐ Ophthalmic ointment to eyes
☐ Heat to prevent hypothermia
☐ Cooling to prevent hyperthermia
☐ Other
Explain: Click here to enter text.
☐ None
Explain: Click here to enter text.
6.
Monitoring during Anesthesia: Indicate below the methods that will be used for monitoring animal condition
and depth of anesthesia during surgery:
☐ Respiratory rate/effort Frequency recorded?:
Click here to enter text.
☐ Heart rate
Click here to enter text.
Frequency recorded?:
☐ Reflex (specify): Click here to enter text. Frequency recorded?: Click here to enter text.
☐ Mucous membrane color
☐ Blood pressure
Frequency recorded?:
Frequency recorded?:
Click here to enter text.
Click here to enter text.
☐ Body temperature
Frequency recorded?:
Click here to enter text.
☐ Oxygen saturation
Frequency recorded?:
Click here to enter text.
☐ Capillary refill time Frequency recorded?:
Click here to enter text.
☐ EKG
Click here to enter text.
Frequency recorded?:
☐ Other Specify: Click here to enter text.
Frequency recorded?: Click here to enter text.
7. Intra-Operative Anesthesia: Please list all agents and dosing regimens:
Drug Name
Dose
Route
Frequency of
Administration
Anticipated
Duration of
Effect
Choose an item.
Click here to
enter text.
Click here to Click here to enter
enter text.
text.
Click here to
enter text.
Choose an item.
Click here to
enter text.
Click here to Click here to enter
enter text.
text.
Click here to
enter text.
8. Post-Operative Animal Support / Recovery from Anesthesia: Indicate care that will be provided to animals
during post-operative recovery (i.e., until sternal recumbancy is regained and maintained). Select all that
apply:
☐ Heat to prevent hypothermia
☐ Intravenous fluids
☐ Ophthalmic ointment to eyes
☐ Other Explain:
Click here to enter text.
☐ None Explain:
Click here to enter text.
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9.
Monitoring During Recovery from Anesthesia: Indicate below the method(s) that will be used for postoperative monitoring of animal condition during recovery from anesthesia. Select all that apply:
☐ Respiratory rate/effort
☐ Reflex (specify):
Click here to enter text.
☐ Mucous membrane color
☐ Capillary refill time
☐ Other Specify:
Click here to enter text.
10. Pain Management: Will analgesia be provided to the animal for relief of post-operative pain?
☐ No. Post-operative analgesia will not be provided. Explain why analgesia will be withheld:
Click here to enter text.
☐ Yes. Analgesia will be provided.
IF YES, please list analgesics and dosing regimens below:
Drug Name
Dose
Route
Frequency of
Administration
Anticipated
Duration of
Effect
Choose an item.
Click here to
enter text.
Click here to Click here to enter
enter text.
text.
Click here to
enter text.
Choose an item.
Click here to
enter text.
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enter text.
text.
Click here to
enter text.
11. Post-Operative Antibiotic or Drug Therapy: Will antibiotics or drugs other than experimental agents be
provided to animals during the post-operative period?
☐ No. Such treatment is not planned and will be provided only if medically advised.
☐ Yes. Antibiotics and/or drugs will be administered.
IF YES, please complete table below.
Drug Name
Dose
Route
Frequency of
Administration
Anticipated
Duration of
Effect
Click here to enter
text.
Click here to
enter text.
Click here to Click here to enter
enter text.
text.
Click here to
enter text.
Click here to enter
text.
Click here to
enter text.
Click here to Click here to enter
enter text.
text.
Click here to
enter text.
Section 2: Non-Survival Surgery
☐ N/A
1. Provide a description of surgery to be performed, including anatomy and organs involved, location and size
of incisions, method and materials for wound closure, and description of implanted materials/devices.
Click here to enter text.
2. Location of Surgery
a. Will surgery be performed in the Vivarium or at another location?
☐ In the Vivarium only
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☐ At another location. If performed at another location please provide the following:

Location (building and room): Click here to enter text.

Duration of animal time outside of the Vivarium prior to euthanasia: Click here to enter text.
Hours

Surgical Equipment/Instrumentation (describe): Click here to enter text.

Describe how the surgical room set up will ensure an aseptic or clean environment (e.g.,
separate dedicated space for surgical procedures, draping, sterile instrument packs,
presence/absence of anesthetics at location [i.e. does location have isoflurane set-up or does PI
have the appropriate vials of injectable drugs on hand?], location of sink and type of activating
mechanism [i.e. foot pedals to turn sink on/off], appropriate surgical attire, etc.):
Click here to enter text.

Carcass and cage disposition: Describe procedures for addressing carcass disposition and cage
removal including how long between end of procedures/euthanasia cages will be removed from
lab area and carcasses will be moved to the Vivarium:
Click here to enter text.
3. Pre-Operative Animal Support (not anesthesia): Specify pre-operative actions taken to prepare the animals
for non-survival surgery (select all that apply):
☐ Physical exam
☐ Overnight food withdrawal
☐ Body temperature support
☐ Clipping of fur
☐ Ophthalmic ointment to eyes
☐ Chlorhexidine + alcohol scrub
☐ Fluids (list) Click here to enter text. OR Other: Click here to enter text.
4. Pre-Operative Anesthesia/Analgesia: Will pre-operative anesthesia/analgesia be provided to animals?
☐ No. Drugs will not be administered to the animals prior to surgical anesthesia
☐ Yes. Pre-operative drugs will be used. Complete table below
IF YES, please complete table below.
Drug Name
Dose
Route
Frequency of
Administration
Anticipated
Duration of
Effect
Choose an item.
Click here to
enter text.
Click here to Click here to enter
enter text.
text.
Click here to
enter text.
Choose an item.
Click here to
enter text.
Click here to Click here to enter
enter text.
text.
Click here to
enter text.
5. Paralytics Use:
a. Will paralytics be used at any time during the procedure?
☐ No. Paralytics will not be used.
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☐ Yes. Paralytics will be used.
IF YES, please complete table below.
Route
Frequency of
Administration
Anticipated
Duration of
Effect
Drug Name
Dose
Click here to enter
text.
Click here to
enter text.
Click here to Click here to enter
enter text.
text.
Click here to
enter text.
Click here to enter
text.
Click here to
enter text.
Click here to Click here to enter
enter text.
text.
Click here to
enter text.
b. If YES, provide justification for their use:
Click here to enter text.
6. Intra-Operative Animal Support: Specify intra-operative care that will be provided to animals during survival
surgery (select all that apply):
☐ Mechanical ventilation
☐ Intravenous fluids
☐ Ophthalmic ointment to eyes
☐ Heat to prevent hypothermia
☐ Cooling to prevent hyperthermia
☐ Other
Explain: Click here to enter text.
☐ None
Explain: Click here to enter text.
7. Intra-Operative Anesthesia: Please list all agents and dosing regimens:
Drug Name
Dose
Route
Frequency of
Administration
Anticipated
Duration of Effect
Choose an item.
Click here to
enter text.
Click here to Click here to enter
enter text.
text.
Click here to enter
text.
Choose an item.
Click here to
enter text.
Click here to Click here to enter
enter text.
text.
Click here to enter
text.
8. Monitoring during Anesthesia: Indicate below the methods that will be used for monitoring animal
condition and depth of anesthesia during the surgical procedure:
☐ Respiratory rate/effort Frequency recorded?:
Click here to enter text.
☐ Heart rate Frequency recorded?:
Click here to enter text.
☐ Reflex (specify): Click here to enter text. Frequency recorded?: Click here to enter text.
☐ Mucous membrane color Frequency recorded?:
Click here to enter text.
☐ Blood pressure Frequency recorded?:
Click here to enter text.
☐ Body temperature
Click here to enter text.
Frequency recorded?:
☐ Oxygen saturation Frequency recorded?:
Click here to enter text.
☐ Capillary refill time Frequency recorded?:
Click here to enter text.
☐ EKG Frequency recorded?:
Click here to enter text.
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☐ Other Specify: Click here to enter text. Frequency recorded?: Click here to enter text.
9.
Specimen Collection
a. Will specimens be collected from living animals during the non-survival surgery?
☐ No. Specimens will not be collected from living animals.
☐ Yes. Define the specimen type and collection details below
☐ Fluids (e.g., blood lymph, ascites, CSF, GI fluids, etc.)
Frequency of
Collection
Method of
Disposal
Click here to
enter text.
Click here to enter
text.
Click here to enter
text.
Click here to
enter text.
Click here to enter
text.
Click here to enter
text.
Collection Method
Volume per
Collection (mls)
Click here to
enter text.
Click here to enter
text.
Click here to
enter text.
Click here to enter
text.
Type of Fluid
☐ Solid Tissues
Click here to
enter text.
Click here to enter
text.
Volume per
Collection
(mm3)
Click here to
enter text.
Click here to
enter text.
Click here to enter
text.
Click here to
enter text.
Type of Tissue
Collection Method
Frequency of
Collection
Method of
Disposal
Click here to enter
text.
Click here to enter
text.
Click here to enter
text.
Click here to enter
text.
Appendix C: Surgery
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