(Institute/Center) Training and Experience Form

SECTION A: General Information

Principal Investigator (PI) or Animal User (AU) Name:

ASP#/Title:

Phone No.: Bldg/Rm: Email:

PI Course completion dates: (Initial) (Refresher)

AU Course completion dates: (Initial) (Refresher)

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1) What is your experience or training for procedures you will be performing on this ASP (e.g. number of years working with the species and proficiency with techniques listed such as injections, blood collection, surgery, behavior tests, etc.)?

2) [Name(s) of PI and/or designee] will provide supervision and training in the techniques I will be performing on this ASP until I am fully qualified to perform these animal activities independently.

3) Yes/No: This ASP involves Nonhuman Primates procedures. If yes complete Section B. If no, go to Section C.

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SECTION B: Nonhuman Primate (NHP) Procedures

1) Nonhuman Primate Safety Course: (IC component date)

(Facility component. date(s): ; ;

2) Yes/No There will be “awake” NHP procedures performed as a part of this protocol, e.g. squeezing up for injections, pole/collar, restraint chairs, operant procedures, etc. If Yes – complete 3 and 4. If no, go to Section C.

3) I will be performing the following awake NHP procedures:

4a)_____ I am currently proficient in performing all of the awake NHP procedures that I’ve listed above,

OR

4b) [name(s) of PI or designee] will provide my supervision and training until I am fully qualified to perform these awake NHP procedures proficiently and independently.

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SECTION C: Assurances

Yes / No: I have read or will read the final, approved version of this ASP and will limit my activities to performance of only those procedures described in the approved ASP.

Yes / No: I understand my responsibilities for acquiring training on techniques I am asked to perform on animals as described in this ASP, but am not currently proficient in performing. Additionally, if my support role for this ASP changes, I will submit a new T&E form and acquire training prior to performing any new procedures.

Animal User signature:____________________________________________________ Date:_________________

As the PI, I assume the responsibility to ensure that this Animal User’s training and experience for procedures he/she will be performing under this ASP has been or will be assessed, and if this person is not proficient in performing these procedures, training will be provided, and proficiency verified, before the person is allowed to conduct these procedures independently.

Principal Investigator signature:_______________________________________________Date:_________________

___(Institute/Center)____ Training and Experience Form (encl 1)

ClarkTE

2006-08-10

OD/USER

NIH\OD