Institutional Animal Care & Use Committee
Request for Vertebrate Animal Procurement
Name of Person Submitting Request
Name :
Office/Cell Number :
Email: / Animal Emergency Contact for Cage Card
Name:
Cell Phone:
Email:
Principal Investigator:
IACUC Protocol Number: / Preferred animal vendor (Vendors must be approved by GT Veterinarian).
Campus Reference #:
PeopleSoft # to charge: This MUST be the same funding source specified in the approved protocol. If not, the order will not be placed until the discrepancy is resolved.
Do not enter p-card number on this form. GTRC will charge the appropriate PeopleSoft number.
Delivery Instructions
Housing must be preapproved by the PRL Manager (see Animal Housing Space Request Form)
Deliver to PRL IBB Deliver to PRL TEP
Deliver to PRL EBB
Deliver to other than PRL (Special Shipping below) / Requested date of animal arrival / Check if next regularly scheduled delivery date is acceptable.
Special Shipping Instructions
If delivery is to be made to location other than PRL, specify name and telephone number of individual to receive animals:
Name: Phone Number:
For delivery location other than PRL Specify building name, street address, and room number:
Specify Animal Order
Common Name / Species
Stock/Strain / Weight/Age Range Description (For timed pregnant animals, specify gestation at arrival) / # of Animals / Gender:
(M, F, Either)
If a “second choice” is acceptable, please state. For example: If E19 animal is not available, what pregnancy range will you accept?
Certifications by Principal Investigator, Co-PI, lab manager, or official designee:
CERTIFICATIONS: I certify that the number of animals requested in this order plus the number of animals received in previous orders does not exceed the number of animals approved by the IACUC for this protocol. I further certify that these charges are allocable to the funding source whose PeopleSoft # is specified above and that this funding source is specified in this IACUC approved protocol.
______
Printed Name of Person Placing Order Signature of Person Placing Order Date
For all animals to be housed in
Physiology Research Laboratory:
RETURN COMPLETED FORM TO PRL MANAGER. / For delivery of animals to location other than PRL:
FAX this completed form to GTRC
Fax: 404.385.2078 Voice: 404.894.9035
PRL Use Only
______Animal Housing Space Request is on file.
______Animal numbers have been verified.
______Interdepartmental charge form with adequate funds on file in PRL
PRL Housing Location Room ______
Rodent Cage Population ______
Shipment Arrival Date ______
Signature, PRL Manager or Delegate / GTRC Use Only
Approved animal protocol & numbers verified.
For PRL housing, PRL Manager/Delegate signature obtained.
Vendor’s Customer Svc Rep______
Vendor’s Order Reference # ______
Vendor’s Promised Delivery Date ______
(If PRL housing, GTRC will fax completed RAP to PRL at 404.385.2610).
Signature GTRC
Georgia Institute of Technology Request for Vertebrate Animal Procurement
Office of Research Integrity Assurance August 2017
IACUC Page 1