O SECTION
ANIMAL EXPERIMENTS INVOLVING HAZARDOUS AGENTS
Complete only if applicable to your project.
This portion of the protocol is for applications using hazardous agents IN VIVO such as radioisotopes, infectious agents,
carcinogens or toxic chemicals. Because many of the questions are “agent-specific”, unless toxicity/treatment/etc. are the
same, please duplicate this form for each agent.
O.1. Study Involves:
Radioactive Materials or Radiation
Infectious Agents (pathogenic to human or animal)
Acute Toxins
Known or suspect chemical carcinogens or mutagens
Recombinant or non-Recombinant DNA/RNA
Other (Describe)
O.2. STATUS OF REVIEW by the appropriate Hazards Committee (Attach approval(s) (If pending approval, a copy
must be submitted as soon as approval is obtained)
Committee Name(s)
Approval date(s)
O.3. Identify agent
O.3.a.
Agent/Chemical/Isotope
O.3.b.
Species
O.3.c.
Dose (Max Vol)
O.3.d.
Route
O.3.e.
Needle Size
O.3.f.
Frequency
YES
NO
O.4. Are there risks to humans? ((If YES, complete the following)
O.4.a.
Method of exposure
How could humans be exposed (e.g.,
excreted in animal’s feces or urine.
Airborne. Only on direct contact with
contaminated animal, etc.)?
O.4.b.
O.4.c.
O.4.d.
Signs/Symptoms
Treatment
Protection (Personal
Protective Devices)
YES
NO
O.5. Are there risks to other animals in the room or animal facility? (If YES, complete the
following) Can other animals in the same room or in the facility become exposed (infected, contaminated, affected, etc.)?
O.5.a.
Method of exposure How could
the other animals in the facility be
exposed (e.g. excreted in feces or urine.
Airborne. Only on direct contact with
contaminated animal, etc.)?
O.5.b.
O.5.c.
O.5.d.
Signs
Treatment
Protection
O.6. Describe experimental procedures
involving hazardous agents
YES
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NO
O.7. Is the duration of hazardous agents use the same as the total project duration? If different,
state approximate time period.
Start Date
Stop Date
YES
NO
YES
NO
YES
NO
O.8. Is there special animal care required relating to the use of hazardous materials?
(If YES, please describe)
O.9. Are there special containment facility requirements? (If YES, complete below)
O.9.a.
Biohazard Room Outside the Animal Facility
O.9.b.
Biohazard Room Within the Animal Facility
O.9.c.
Other Containment Requirements
(Please Describe)
O.10. Are there waste and animal disposal
requirements? (If YES, describe)
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