Animal use request form URI Peckham Farm Animal Use Request Form Principal Investigator(Required) First Last Department(Required) Phone(Required)Co-researcher(s)/Affiliation Experiment / Function Title IACUC Protocol # 1. Please indicate which species you are requesting and species life stage? 2. Is this a multi-year project? Yes No 3. Total number of animals requested per project year? Estimated start date for each project year MM slash DD slash YYYY Estimated end date for each project year MM slash DD slash YYYY 4. Does the research involve treatment that will require extra costs and/or alter the production level or sale value of the animal or its offspring? Yes No If yes, explain: 5. If answering 'yes' to any of the following, please explain: a. Terminal for the animal Yes No If yes, explain: b. Permenant alteration because of surgery, diet, or other treatment Yes No If yes, explain: c. Affects growth and development Yes No If yes, explain: d. Affects the breeding age or breeding data Yes No If yes, explain: e. Movement from facility Yes No If yes, explain: 6. What services, other than availability of animals, will be requested of regular animal caretakers? 7. What are you requesting the Peckham Farm facility to supply? 8. What will you supply? 9. Monetary or in-kind support? NameThis field is for validation purposes and should be left unchanged. Δ
