ACORP Appendix 7
Request to Use Patient Care Procedural Areas for Animal Studies
Version 3

1.	Name of Principal Investigator(s):  

2.	Provide a concise statement of the potential benefit to VA patients if a patient care area is used for research involving animals.  

3.	Why can’t the animal facility or a laboratory area be utilized for the proposed procedures?  

4.	Identify the species and number of animals to be used.  

5.	Discuss the potential pain and/or distress to animal subjects during the procedures to be conducted in a patient procedural area, and interventions planned for the prevention or alleviation of such pain/distress.  

6.	Identify the equipment and location (building and room numbers) of the patient care area(s) to be used.  

7.	List the date(s) and time of day that the procedure(s) will be performed.  

8.	Discuss the method of transporting the animals to and from the procedural area.  Include a description of the transport containers, any vehicles used, and precautions to be taken to avoid contact with patients, visitors, and other non-research personnel.  

9.	Provide a complete description of the measures to be taken to prevent the transmission of zoonotic pathogens from animals to patients and patient care personnel.  

10.	Provide a complete description of the measures to be taken to prevent disturbances (e.g., noise, odors) to patients and patient care personnel.  

11.	Provide a complete description of methods to be employed to prevent contamination of equipment and room surfaces by animal feces, urine, saliva, blood, or other body fluids.  

12.	Provide details of the procedures to be followed in cleaning and disinfecting equipment and room surfaces following use.  

13.	Required signatures.  (If this appendix is part of an ACORP, return to item X.3. on the ACORP.)  

a.	Principal Investigator(s) submitting this request.  

Name(s) of Principal Investigator(s) (typed)	Signature(s)	Date	

			

b.	Approving officials.  

Name of IACUC Chair (typed)	Signature	Date	
			
Name of Attending Veterinarian (VMO or VMC, typed)	Signature	Date	
			
Chair, Clinical Executive Board or Service Chief responsible for the patient care equipment (typed)	Signature	Date	
			
ACOS for R&D (typed)	Signature	Date	
			
Chief of Staff  (typed)	Signature	Date	
			
Facility (Hospital or Clinic) Director or CEO (typed)	Signature	Date