ACORP Appendix 8
Request to Use Explosive Agent in the Animal Facility or in Animals
Version 3 

1.	Principal Investigator(s):  

2.	Give the name(s), title(s), and prior pertinent training and experience of individuals who will administer the explosive agent.  

3.	Name of the explosive agent(s), and the Material Safety Data Sheet number(s):  

4.	Why can’t a non-explosive agent or agents be used instead?  

5.	Give the beginning and ending dates during which the explosive agent(s) will be used.  

6.	Give a brief description of the studies for which the use of an explosive agent is proposed.  

7.	Give the species, weight, and approximate number of animal subjects that will be administered the explosive agent(s).  

8.	Give the building and room number in which agent(s) will be used.  

9.	Give a detailed description of the procedure(s) involving the explosive agent(s) including assurances that:  a) procedures are performed within a properly operating, ventilated safety hood, b) all electrical equipment used with the agent are placed and powered outside the hood, c) once the seal is broken on containers of ether or other explosive anesthetic agents, they will be placed into a safety hood throughout use, stored in an explosion proof refrigerator or other approved storage area, and discarded properly once completely used, and d) that proper disposal procedures for items (including carcasses) containing traces of the agent will be safe and appropriate.  (When finished, proceed to item Y on the ACORP.)  

10.	Required signatures.

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	
			
Facility Safety/Biosafety Officer (typed)	Signature	Date	
			
ACOS for R&D (typed)	Signature	Date	
			
VISN Regional Safety Officer  (typed)	Signature	Date