Principal investigator (PI) detail

PRINCIPAL INVESTIGATOR (PI) DETAIL - The PI whose protocol number will be used to record animal use.
PI Last Name:  				PI First Name:      					Order Date (mm/dd/yy):      
PI Charge Account #: (4 Digit Speed code or Other #)      					5.1. Is this a new charge account?  Yes  No 5.2. Is this another PI’s charge account?  Yes  No If another PI’s account is used, ensure other PI is copied on the email form submission.
PI Protocol Number: (1 protocol per form)      					Select Protocol Type for the animals ordered below: 
Will the animals requested below be subjected to hazardous materials – biohazards, chemicals, imaging materials or devices – at any time during housing within the HSACF or WV or Robarts facilities?  Yes  No If ‘YES,’ specify hazardous material(s) used:      
PRIMARY RESEARCH TECHNICIAN RESPONSIBLE FOR ANIMAL CARE of SECTION IV. ANIMALS
Last Name:  Same as Principal Investigator, or      			First Name:  Same as Principal Investigator, or      				Has this individual’s name been added to the above listed protocol?  Yes  No
Work Phone #:      	After Hours Emergency Contact # for ACVS staff :      							Email:      
FACILITY ACCESS Does this staff member have current security card access to the HSACF?  Yes  No If ‘NO’, has the Card Access Request form been submitted to the [e-mail]?  Yes  No					ANIMAL TRAINING 8.1. Check all up-to-date Veterinary Services animal training completed by the primary research technician responsible for Sect.IV animals’ care:  Animal Care & Use WebCT Lecture  Species-specific Basic Behaviour, Handling & Euthanasia  Monitoring If the above training is not up-to-date, has a training application form been sent to [e-mail]?  Yes  No
Does this staff member require specialty housing/facility access?  Yes  No If ‘YES’, specify special housing/facility access requirements:      
REQUESTOR DETAIL - Individual responsible for submitting commercial animal requisitions.
 Same as Principal Investigator, Go to IV.  Same as Primary Research Technician Responsible for Animal Care, Go to IV.
Last Name:      						First Name:      
Contact #:      		Email:      

ANIMAL ORDER DETAIL

1. ANIMAL DETAIL

2. VENDOR DETAIL

3. FACILITY HOUSING PREFERENCES

Animal #

Species

Strain & Vendor Stock #, If Available

Age Weight Timed Pregnancy Detail

M/F

Pheno- Type? If ‘Yes’ Complete IV. 4.

Requested Delivery Date mm/dd/yy

Preferred Vendor

Housing Type & Facility Name

Caging Type

Facility Room # Reqd.

Approx. Time of Stay

     

 If Other:      

     

     



 Yes  No

     

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Type:  Name: 



     

     

     

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Type:  Name: 



    

     

     

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Type:  Name: 



     

     

     

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Type:  Name: 



     

     

     

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 Yes  No

     

 If Other,      

Type:  Name: 



     

     

4. If Phenotype = YES, identify all special animal care concerns related to phenotype

     

5. Provide Other Important Animal Ordering Details, e.g. specialized caging, shipping or delivery requests

     

OFFICE USE ONLY:

SIRIUS REQUISITION #:      

OTHER VENDOR DETAIL: