(see Item 1) Other (describe) Manage Surgeon Assistant Anesthesia ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Location of surgery. Complete the table below for each location where surgery on this protocol will be performed. Type of Space Surgery Other Other Room #(s) Dedicated Building Dedicated Space not Number (see Surgical Surgical Dedicated Item 1) Facility Space to Surgery ( ) ( )* ( )* ( ) ( *) ( )* ( ) ( )* ( )* ( ) ( )* ( )* *For each space that is not in a dedicated surgical facility, provide the justification for using this space for surgery on this protocol ► Pre-operative protocol. Pre-operative procedures. Complete the table below for each pre-operative procedure that will be performed to prepare the animal(s) for surgery. Surgery Withhold Place Fast #(s) Water Intravenous (Specify Other Describe – (see (Specify Catheter(s) Duration) Item 1) Duration) (Specify Site(s)) 1 ( ) -- ( ) -- ( ) -- ( ) -- 2 ( ) -- ( ) -- ( ) -- ( ) -- 3 ( ) -- ( ) -- ( ) -- ( ) -- 4 ( ) -- ( ) -- ( ) -- ( ) --
(see Item 1) Surgeon Assistant Manage Anesthesia Other (describe) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Location of surgery. Complete the table below for each location where surgery on this protocol will be performed. Building Room Number Surgery #(s) (see Item 1) Type of Space Dedicated Surgical Facility Other Dedicated Surgical Space Other Space not Dedicated to Surgery ( ) ( )* ( )* ( ) ( *) ( )* ( ) ( )* ( )* ( ) ( )* ( )* *For each space that is not in a dedicated surgical facility, provide the justification for using this space for surgery on this protocol ► Pre-operative protocol. Pre-operative procedures. Complete the table below for each pre-operative procedure that will be performed to prepare the animal(s) for surgery. Surgery #(s) (see Item 1) Fast (Specify Duration) Withhold Water (Specify Duration) Place Intravenous Catheter(s) (Specify Site(s)) Other – Describe 1 ( ) -- ( ) -- ( ) -- ( ) -- 2 ( ) -- ( ) -- ( ) -- ( ) -- 3 ( ) -- ( ) -- ( ) -- ( ) -- 4 ( ) -- ( ) -- ( ) -- ( ) --
ACORP%20Version%204-534.docx