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California State University, Long Beach
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Maintenance and Animal Observation Form (rev. 9/10)

Download this form in Word. When finished, e-mail the form to the Attending Veterinarian, John Young, for review.  After his review, e-mail the form to for placement on an IACUC meeting agenda.

(Note: This form must be typed; handwritten forms will not be accepted.)

IACUC Project Number:
  1. Responsible Faculty Member
    • Name:
    • Department:
    • Office Location:
    • Extension:
    • E-mail Address:
  1. Description
    • Provide a brief explanation and rationale for maintenance and observation of animals in classroom/office.
  1. Animal Information
    1. Species/Strain:
    2. Sex:
    3. Age/Size:
    4. Breeding Necessary: Yes ____ No ____
    5. Vendor Source:
    6. Number to be maintained:
    7. Animal Housing Location (Bldg/Rm):
  1. Animal Facilities
    1. Description of primary enclosure (housing unit for animals).
    2. Description of routine husbandry including frequency of activity (feeding, watering, cage sanitation, environmental temperature, etc.).
    3. Provisions for husbandry of animals during weekdays, weekends, holidays, vacations, etc.
    4. Provisions for veterinary consultation and/or euthanasia in the event of a health problem.
Signature and Date:

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