**ACORP Appendix 7**

**[Request to Use Patient Care Procedural Areas for Animal
Studies]{.smallcaps}**

**Version 3**

1\. Name of Principal Investigator(s):[ ]{#Text1}

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?[ ]{#Text3}

4\. Identify the species and number of animals to be used.[ ]{#Text4}

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.[ ]{#Text5}

6\. Identify the equipment and location (building and room numbers) of
the patient care area(s) to be used.[ ]{#Text6}

7\. List the date(s) and time of day that the procedure(s) will be
performed.[ ]{#Text7}

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.[ ]{#Text8}

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.[ ]{#Text9}

10\. Provide a complete description of the measures to be taken to
prevent disturbances (e.g., noise, odors) to patients and patient care
personnel.[ ]{#Text10}

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.[ ]{#Text11}

12\. Provide details of the procedures to be followed in cleaning and
disinfecting equipment and room surfaces following use.[ ]{#Text12}

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.

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  Name(s) of Principal Investigator(s) (typed)   Signature(s)   Date
                                                                
                                                                
                                                                
                                                                
                                                                
                                                                
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b\. Approving officials.

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  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
                                                                                                                    
                                                                                                                    
                                                                                                                    
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