Tufts CMS PI Authorization Form

PI Authorization of Acquisition of DEA Controlled Substances
These individuals are authorized to obtain the indicated controlled substances from CMS for use in laboratory animals according to the approved protocols.

Please provide the information below for each IACUC Protocol.

Upon submission of this form, a verification e-mail will be sent to the e-mail listed for the Principal Investigator. CMS will alerted once this form has been verified by the Principal Investigator.

Questions about this form? Please contact tuftscms-pi-auth@elist.tufts.edu .
Principal Investigator Name

First NameLast Name
Principal Investigator E-mail (University, Medical Center, or Company e-mail should be used)
example@example.com
RE-ENTER E-MAIL. Principal Investigator E-mail (University, Medical Center, or Company e-mail should be used)
example@example.com
When both e-mails entered are identical, the rest of the form will appear.
Protocol Number
Only list one protocol number. Additional protocols can be added below
Which drugs are being authorized under this protocol? (Check all that apply)

BuprenorphineBuprenorphine-SR (Sustained Release)KetamineDiazepamTelazolPentobarbital
If not listed above, enter drugs being authorized under this protocol
Name of Authorized Personnel #1

First NameLast Name
Name of Authorized Personnel #2

First NameLast Name
Name of Authorized Personnel #3

First NameLast Name
Name of Authorized Personnel #4

First NameLast Name
Name of Authorized Personnel #5

First NameLast Name
Name of Authorized Personnel #6

First NameLast Name
Name of Authorized Personnel #7

First NameLast Name
Name of Authorized Personnel #8

First NameLast Name
Name of Authorized Personnel #9

First NameLast Name
Name of Authorized Personnel #10

First NameLast Name
Notes:
Protocol Number
Only list one protocol number. Additional protocols can be added below
Which drugs are being authorized under this protocol? (Check all that apply)

BuprenorphineBuprenorphine-SR (Sustained Release)KetamineDiazepamTelazolPentobarbital
If not listed above, enter drugs being authorized under this protocol
Name of Authorized Personnel #1

First NameLast Name
Name of Authorized Personnel #2

First NameLast Name
Name of Authorized Personnel #3

First NameLast Name
Name of Authorized Personnel #4

First NameLast Name
Name of Authorized Personnel #5

First NameLast Name
Name of Authorized Personnel #6

First NameLast Name
Name of Authorized Personnel #7

First NameLast Name
Name of Authorized Personnel #8

First NameLast Name
Name of Authorized Personnel #9

First NameLast Name
Name of Authorized Personnel #10

First NameLast Name
Notes:
Protocol Number
Only list one protocol number. Additional protocols can be added below
Which drugs are being authorized under this protocol? (Check all that apply)

BuprenorphineBuprenorphine-SR (Sustained Release)KetamineDiazepamTelazolPentobarbital
If not listed above, enter drugs being authorized under this protocol
Name of Authorized Personnel #1

First NameLast Name
Name of Authorized Personnel #2

First NameLast Name
Name of Authorized Personnel #3

First NameLast Name
Name of Authorized Personnel #4

First NameLast Name
Name of Authorized Personnel #5

First NameLast Name
Name of Authorized Personnel #6

First NameLast Name
Name of Authorized Personnel #7

First NameLast Name
Name of Authorized Personnel #8

First NameLast Name
Name of Authorized Personnel #9

First NameLast Name
Name of Authorized Personnel #10

First NameLast Name
Notes:
Name of individual completing form

First NameLast Name
E-mail of individual completing form (University, Medical Center, or Company e-mail should be used)
example@example.com
RE-ENTER E-MAIL. E-mail of individual completing form (University, Medical Center, or Company e-mail should be used)
example@example.com
When both e-mails entered are identical, the submit button will appear.
By submitting submit, a verification e-mail will be sent to the e-mail listed in this form for Principal Investigator. Tufts CMS will be notified of form submission once the Principal Invesitgator has verified this from.
Should be Empty: