UConn Health Initial Animal User Training Request If you will be participating in laboratory animal work at UConn Health in Farmington, please complete this form. Please fill out the form completely. Incomplete forms will be returned and training will not be scheduled. Contact InformationName* First Middle Last Department* Job Title* Job TypeFull-Time EmployeePart-Time EmployeeSpecial Payroll EmployeeTemporaryStudentInternVolunteerHiddenUConn Health Network Account Username Enter your UConn Health Active Directory domain network account username that is used to login to the UCH network and computers. DO NOT ENTER THE PASSWORD! Just the username. Don't have a UCH network account username? Have your Principal Investigator or Department Administrator request one via an on-campus computer at https://uar.uchc.edu. All UConn Health employees and students have a network account but it must be manually requested for vendors, external affiliates (e.g. Jackson Lab employees, TIP employees), volunteers, student interns, UConn Storrs students, and some temporary special payroll employees. All animal users must have a UCH network login to register for training and gain access to Topaz Elements. Please come back and register after you obtain this username if you do not have one currently. NetID* Enter your UConn NetID. If you do not know what your UConn NetID is, you can look it up at this location: https://netid.uconn.edu/find_netid.php UConn Health (UCHC) Email:*If you do not have a UCHC email address, work with your dept. administrator to obtain one. Enter Email Confirm Email PhoneOther Email AddressEnter your company email address if other than UCH, such as a TIPS company or Jax lab. Enter Email Confirm Email Date of Birth* Month Day Year Gender*MaleFemalePrefer Not to AnswerHighest Degree*High School or GEDAssociate DegreeBachelor's DegreeGraduate CertificateMaster's DegreeDoctoral DegreeSome CollegePrefer Not to AnswerSelect the highest degree you have obtained. What is the name of the Principal Investigator (PI) that you will be working with?* Initial IACUC TrainingTraining Session Date Requested*Refer to the IACUC Training Schedule for a listing of training dates. Month Day Year Skills and ExperienceWhat species are you going to use?* Birds Cats Chinchillas Fish Gerbils Guinea pigs Hamsters Mice Rats Nonhuman primates Not sure Other Other Species to be usedCreate a new line for each species. Click the + sign to add a new row. What procedures are you likely to use on animals?* Handling Injections Euthanasia Survival surgery Husbandry Non-survival surgery Post-procedural monitoring Use of restraints Unknown Other Other Procedures Likely UsedEnter each procedure as a separate line. Click the + sign to add a new row. Will you be using hazardous substances when working with animals?* No Not sure Yes Hazardous Substances to be usedEnter each substance on a new line and then click the plus sign to add another hazardous substance row. Repeat as needed. Have you had any previous training in the use of laboratory animals?* No Yes Prior Animal Training ExperienceDosingList each technique. Examples include IV, IM, SC, IP, PO FP, or IC. Click the plus sign to add additional rows as needed. MethodExperience in YearsSpeciesInstitution Where Training OccurredDate Training Completed Handling & RestraintExperience in YearsSpeciesInstitution Where Training OccurredDate Training CompletedAnimal Identification MethodsList each method. Examples include ear punch, ear tag, chip implant, tattoo, toe clip, or branding. Click the plus sign to add additional rows as needed. MethodExperience in YearsSpeciesInstitution Where Training OccurredDate Training Completed Blood CollectionList each type. Examples include IV, Saphenous, RO, Tail Nick, or Cardiac Puncture. Click the plus sign to add additional rows as needed. MethodExperience in YearsSpeciesInstitution Where Training OccurredDate Training Completed AnesthesiaList each method. Examples include injectible or inhalation. Click the plus sign to add additional rows as needed. MethodExperience in YearsSpeciesInstitution Where Training OccurredDate Training Completed EuthanasiaList each method. Examples include CO2, Cervical Dislocation, Decapitation, Injectible, or Pithing. Click the plus sign to add additional rows as needed. MethodExperience in YearsSpeciesInstitution Where Training OccurredDate Training Completed Aseptic Surgery TechniqueExperience in YearsSpeciesInstitution Where Training OccurredDate Training Completed Other Surgical ProceduresList training using different surgical procedures. Click the plus sign to add additional rows as needed. Name of ProcedureExperience in YearsSpeciesInstitution Where Training OccurredDate Training Completed Personal Agreement • I will perform my duties in accordance with the Animal Welfare Act, the USDA regulations, the PHS Policy on Humane Care and Use of Laboratory Animals, the current AVMA Guidelines on Euthanasia, and the current Guide for the Care and Use of Laboratory Animals. • I will review the protocol(s) under which I will be performing work and will be responsible for conducting this work as it is stated in the IACUC approved protocol. • I will ensure that IACUC approval has been received before conducting any procedures not listed in the original protocol(s). • I will immediately notify the attending veterinarian, my Principal Investigator (PI), and the IACUC when any unanticipated animal pain/distress or unexpected morbidity/mortality occurs within any of my studies. Certification* I have read the above and agree to the terms PhoneThis field is for validation purposes and should be left unchanged.