VERTEBRATE ANIMAL CLASSROOM USE DEMONSTRATION OR DISPLAY SHORT FORM

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Vertebrate Animal Classroom Use, Demonstration or Display Short Form

Bringing vertebrate animals from an off-campus source into a UMass classroom or UMass property may require review and approval by the Institutional Animal Care and Use Committee (IACUC). You will either be required to complete an IACUC protocol https://www.umass.edu/research/kuali-era-system or describe the proposed use on this short form.

Course (Schedule Number and Title): ___________________________________________________________

Date, time and location of the class where the animals will be used:

_____________________________________________________________________________________________

Instructor:

__________________________________________________ Dept.______________________________________

Telephone: _________________________________________ e-mail: ____________________________________

Responsible Faculty Member (if not the Instructor):

__________________________________________________ Dept.______________________________________

Telephone: _________________________________________ e-mail: ___________________________________

Veterinarian contact: [name of a veterinarian who can certify the animal(s) appear healthy and have up to date vaccinations]: _________________________________________________________________________________

Address: _____________________________________________________________________________________

Telephone: __________________________________________ e-mail: __________________________________

Date of last rabies vaccination: ___________________________________________________________________

Animal owner: _______________________________________________________________________________

Address: _____________________________________________________________________________________

Telephone: ________________________________________ e-mail: _____________________________________

Description of the proposed use of animals

1. Species and number: _________________________________________________________________

2. Source of the animal(s) (e.g. wild-caught, pet, animal shelter etc.): ____________________________

3. How will the animal(s) be transported to campus? ________________________________________

4. Caging/restraint method(s) used while animals are in transit and on campus:

_____________________________________________________________________________________

5: How much time will the animals spend in the classroom? ___________________________________

6: How much time including class time will the animals be on campus? _____________________________________________________________________________________

7: Holding location if needed while on campus but not in the classroom (Building, room #)?

_____________________________________________________________________________________

8. Date of most recent veterinary check: ___________________________________________________

9. Briefly describe your purpose in bringing the animals to class:

____________________________________________________________________________________

_____________________________________________________________________________________

10. Describe how you will ensure adequate sanitation while the animals are on the UMass campus:

_____________________________________________________________________________________

11. Other comments:

_____________________________________________________________________________________

Signatures

I certify that:

The proposed use of animals is for teaching purposes.

The students will have no contact with the animal(s).

A veterinarian has certified within the past month that the animal(s) appear healthy, present no obvious behavioral hazard, and have had species-appropriate vaccinations.

The students may be offered the opportunity to participate in the Occupational Health and Safety Program (OHSP) for animal users prior to the class. Allow 2 weeks for review of OHSP forms.

__________________________________________ ________________

(Responsible Faculty Member) Date

VERTEBRATE ANIMAL CLASSROOM USE DEMONSTRATION OR DISPLAY SHORT FORM