Technician and PI Information

Technician's name Technician's email

Technician's day phone Technician's after hours phone

PI name AUP #

Agent Information

New Request Repeat Request - Last date requested:

Facility where work is being done Health Sciences Animal Care Facility West Valley Building Robarts Research Institute

Room # Number of cages affected

Agent name Agent Supplier

Agent Category Chemical Biological Level 1 Biological Level 2 Biological Level 2+/3

Timelines

Requested Start Date Requested End Date Time of Injection AMPM

Agent Clearance Time (when will the agent be fully excreted from the animal) (For Chemicals/Pharmaceuticals only)

Project End Date (date of animal euthanasia - for biologicals only)

Training Confirmation and Back-Up Technician

I confirm that I (and my back-up) have the appropriate room and safety training regarding the administration of this agent

Name of Back-up technician (Must be on AUP)

Back-up technician email

Back-up technician day phone

Back-up technician after hours phone