Page 10 Revised December 2019
(Complete only if applicable or mark N/A here )
1. Class of the test substances or other material:
B. Infectious Agent
D. Toxic Chemical
G. Antigenic substance
I. Excreta or Body Fluids
J. Pharmacological Agent
2. Identify the test substances or other material that will be administered to the animals:
SUBSTANCE NAME CLASS DOSE FREQUENCY ROUTE DURATION
3. Will the test substance(s) cause pain or distress to the animal?
NO - PROCEED TO ITEM 4.
YES - Describe the measures that will be taken to alleviate or minimize these effects.
4. Is the test substance considered to be a hazardous material?
NO - STOP HERE.
YES - Give names of personnel who will work with hazardous material then proceed to ITEM 5:
5. If you are using any radio-isotope, or hazardous material of any type, you must have authorization to work with
these materials by the Director of Environmental Health and Safety. The Director's signature indicates that he has
consulted with the Attending Veterinarian, and that adequate precautions, containment facilities, protective
devices, carcass and waste disposal, cleanup procedures, and other necessary safety procedures are in place to
protect personnel and prevent accidental animal exposure to the hazardous material. Please provide a letter
documenting the safety precautions that will be used.
Director, Environmental Health & Safety Date
K. Non-Pharmaceutical-grade substance (see below)
When Non-Pharmaceutical-grade substances are used, ensure that toxic or unwanted side
effects are not introduced. Explain if the pharmaceutical grade is not available and provide
justification in the box below or on a separate document. (If applicable, include the pH,
pyrogenicity, osmolality, stability, site and route of administration, formulation, compatibility,
and pharmacokinetics of the chemical or substance to be administered)