Fillable FORM MU-03M: COLUMBUS STATE COMMUNITY COLLEGE FACULTY, STAFF, (Columbus State Community College)

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FORM MU-03M: COLUMBUS STATE COMMUNITY COLLEGE FACULTY, STAFF, (Columbus State Community College)

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FORM MU-03M
COLUMBUS STATE COMMUNITY COLLEGE
FACULTY, STAFF, AND STUDENT PROTOCOL
FOR MISCELLANEOUS ANIMAL USE
DATE RECEIVED __________ DATE REVIEWED __________
CIRCLE ONE: STUDENT, FACULTY, STAFF
NAME: _______________________________________________ PHONE NO. _________________
DATES, TIMES, AND PLACES (BUILDING AND ROOM NUMBER) OF EVENT:
ADDITIONAL COURSE ROOMS AND INSTRUCTORS THAT THE ANIMAL WILL ENTER:
1) CLASS NAME:_________________________________ LOCATION:____________
INSTRUCTOR SIGN:___________________________________________________
2) CLASS NAME:_________________________________ LOCATION:____________
INSTRUCTOR SIGN:___________________________________________________
3) CLASS NAME:_________________________________ LOCATION:____________
INSTRUCTOR SIGN:___________________________________________________
(PLEASE USE ADDITIONAL FORMS IF NECESSARY TO LIST ALL CLASS AND
INSTRUCTORS)
REASON FOR USE OF ANIMAL(S): _____________________________________________________
COLUMBUS STATE COMMUNITY COLLEGE
FACULTY, STAFF, AND STUDENT PROTOCOL
FOR MISCELLANEOUS ANIMAL USE
PAGE 2
WERE ALTERNATIVE METHODS CONSIDERED: ________________________________________
WILL THIS PROCEDURE CAUSE PROLONGED RESTRAINT, PAIN OR DISTRESS: (IF YES,
PLEASE DESCRIBE PROCEDURE IN DEPTH)
WILL ANY ANESTHESIA, ANALGESIA, TRANQUILIZERS OR OTHER RX BE ADMINISTERED:
(IF YES, PLEASE LIST THE DRUG, DOSAGE, AND ROUTE OF ADMINISTRATION)
WILL EUTHANASIA BE PERFORMED: CIRCLE ONE: YES, NO
PLEASE LIST THE SPECIES AND NUMBER OF ANIMALS REQUIRED:
COLUMBUS STATE COMMUNITY COLLEGE
FACULTY, STAFF, AND STUDENT PROTOCOL
FOR MISCELLANEOUS ANIMAL USE
PAGE 3
NOTE: IF THIS PROCEDURE WILL CAUSE PROLONGED RESTRAINT, PAIN OR DISTRESS,
OR IF ANESTHETICS, ANALGESICS, TRANQUILIZERS OR ANY PARENTERAL AGENTS WILL
BE ADMINISTERED, OR IF EUTHANASIA WILL BE PERFORMED, THE PROTOCOL WILL
HAVE TO BE PRESENTED TO AND APPROVED BY THE IACUC COMMITTEE BEFORE THIS
PROCEDURE MAY BE PERFORMED. THE LONG FORM ANIMAL USE PROTOCOL MAY ALSO
HAVE TO BE FILLED OUT.
IF THE ABOVE NOTED TECHNIQUES ARE NOT BEING PERFORMED ON ANY ANIMAL(S),
THE SIGNATURE OF THE ATTENDING VETERINARIAN AND ONE OTHER IACUC MEMBER
IS ALL THAT IS REQUIRED TO USE ANIMALS FOR THE SPECIFIC PURPOSE NOTED IN THIS
PROTOCOL FORM MU-105.
PREPARER SIGNATURE ______________________________ DATE __________
ATTENDING VET SIGNATURE ______________________________ DATE __________
IACUC MEMBER SIGNATURE ______________________________ DATE __________
COLUMBUS STATE COMMUNITY COLLEGE
FACULTY, STAFF, AND STUDENT PROTOCOL
FOR MISCELLANEOUS ANIMAL USE
PAGE 4
ALL DOGS, CATS, AND FERRETS MUST HAVE CURRENT DISTEMPER AND RABIES
VACCINATIONS.
ALL OTHER ANIMALS MUST HAVE CURRENT VACCINATIONS THAT ARE CUSTOMARY
GIVEN TO T
HAT SPECIES.
VACCINATIONS: DATE ADMINISTERED:
THE ATTENDING VETERINARIAN WILL MAKE RECOMMENDATIONS FOR THE METHOD OF
TRANSPORTATION AND RESTRAINT FOR THE ANIMAL(S) ON CAM
PUS.
_____________________________________________________________________________________
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FORM MU-03M: COLUMBUS STATE COMMUNITY COLLEGE FACULTY, STAFF, (Columbus State Community College)

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Completed 26 July 2020

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