Tufts CMS Drug and Supply Request Form

Drug and Supply Request Form
This form is to be used by Tufts research investigators on the Boston and Medford campuses who wish purchase drug and supplies from Tufts CMS. DEA-controlled substances and non-DEA-controlled substances may also be ordered using this form. A list of DEA-controlled substances can be found in the DEA Orange Book.

Investigators are responsible for ensuring that administration of drugs to animals are covered in an approved IACUC protocol. Administering drugs to animals that is NOT described in an IACUC protocol may result in an incident of non-compliance with the IACUC.

Investigators requesting drugs and other supplies should submit this form at least five business days prior to the date needed (Note: Some special orders may take longer than 5 days to procure. This does not include University recognized holidays, bonus days, or weekends). Requested materials may be picked up by pre-arranged time. Please note that missed appointments for picking up drugs or supplies may result in a technical service fee.

If the requested supply is absolutely necessary on a certain date, call 617-636-2674 as soon as possible prior to the date needed.

For ordering controlled substances, please scroll down to bottom of form

Common DEA-controlled substances ordered include: ketamine, buprenorphine, diazepam. Drugs that are NOT controlled substances include, but not limited to, xylazine, antibiotics, atropine, acepromazine, chorulon. For questions regarding controlled substances, please contact TuftsCMS-drugsandsupplies@tufts.edu
Date*

MonthDayYear
Date
Principal Investigator*

First NameLast Name
IACUC Protocol Number:*
Must be a current protocol number
Account Number*
Species*
List all species that are intended to be used
Room(s) in which the animals are currently housed*
If unknown, enter UNK
Requested Pick Up Date*

MonthDayYear
Investigators requesting drugs and other supplies should submit this form at least five business days prior to the date needed. (Note: Some special orders may take longer than 5 days to procure). This does not include University recognized holidays, bonus days, or weekends. Receipt of drugs or supplies by requested date above is not guaranteed.
Which campus would you like this drug/supply be delivered to?*

Non-controlled Drugs and Supplies Request #1
Drug/Supply # 1 Name Requested (Non-controlled substances)
Other Drug/Supply not listed (Non-controlled substances)
Please provide as much detail as possible
Volume Requested of Drug Supply #1
Please note that there may be a minimum volume required to obtain, given the size of the vial/bottle provided by manufacturer
Number of bottles/vials/tubes/packs/cups/etc. for Drug Supply #1
Other notes for Drug Supply #1
If needed, please provide as much detail as possible

Non-controlled Drugs and Supplies Request #2
Drug/Supply # 2 Name Requested (Non-controlled substances)
Other Drug/Supply not listed (Non-controlled substances)
Please provide as much detail as possible
Volume Requested of Drug Supply #2
Please note that there may be a minimum volume required to obtain, given the size of the vial/bottle provided by manufacturer
Number of bottles/vials/tubes/packs/cups/etc. for Drug Supply #2
Other notes for Drug Supply #2
If needed, please provide as much detail as possible

Non-controlled Drugs and Supplies Request #3
Drug/Supply # 3 Name Requested (Non-controlled substances)
Other Drug/Supply not listed (Non-controlled substances)
Please provide as much detail as possible
Volume Requested of Drug Supply #3
Please note that there may be a minimum volume required to obtain, given the size of the vial/bottle provided by manufacturer
Number of bottles/vials/tubes/packs/cups/etc. for Drug Supply #3
Other notes for Drug Supply #3
If needed, please provide as much detail as possible

Non-controlled Drugs and Supplies Request #4
Drug/Supply # 4 Name Requested (Non-controlled substances)
Other Drug/Supply not listed (Non-controlled substances)
Please provide as much detail as possible
Volume Requested of Drug Supply #4
Please note that there may be a minimum volume required to obtain, given the size of the vial/bottle provided by manufacturer
Number of bottles/vials/tubes/packs/cups/etc. for Drug Supply #4
Other notes for Drug Supply #4
If needed, please provide as much detail as possible

Non-controlled Drugs and Supplies Request #5
Drug/Supply # 5 Name Requested (Non-controlled substances)
Other Drug/Supply not listed (Non-controlled substances)
Please provide as much detail as possible
Volume Requested of Drug Supply #5
Please note that there may be a minimum volume required to obtain, given the size of the vial/bottle provided by manufacturer
Number of bottles/vials/tubes/packs/cups/etc. for Drug Supply #5
Other notes for Drug Supply #5
If needed, please provide as much detail as possible

DEA Controlled Substance
Are you requesting a DEA Controlled Substance (including, but not limited to, ketamine, buprenorphine, diazepam, euthasol).

YesNo
Which campus will controlled substance be maintained?*
Prior to requesting controlled substances, investigators will need to be authorized to acquire contolled substances. The following form "Authorization for the Acquisition of Controlled Substances" must be completed and submitted to Tufts CMS.

Investigators utilizing controlled substances must be familiar with the following:
- Tufts CMS Policy on the Secure Storage & Record Keeping of DEA Controlled Substances. All investigators MUST be compliant with this Policy.
- Tufts CMS Controlled Substances Log. All investigators MUST log out controlled substances using this Log Sheet.
- You can find more information on ordering controlled substances from the Tufts CMS Controlled Susbtance Requisition SOP.
- IACUC Policy on the Use of Expired Medical Materials & Non-Pharmaceutical Grade (NPG) Substances in Research Animals. Use of expired anesthetics, analgesics, tranquilizers, emergency drugs, or euthanasia agents in research animals is unacceptable and the IACUC requires that expired medical materials be disposed of once the expiration date has been reached.
- Contact TuftsCMS-drugsandsupplies@tufts.edu for passwords if you don't have access to the links above.
IACUC Protocol Principal Investigator (PI) E-mail Address*
A copy of the controlled drug order will be automatically sent to PI

DEA-Controlled Substance Request #1
Name of DEA-Controlled Substance #1 Requested
For buprenorphine, please indicate if either buprenorphine-sustained release (SR) or regular buprenorphine is requested. As previously mentioned, please note some drugs may take more than 5 days to fill, depending on its availability.
Other Drug not listed
Please provide as much detail as possible
Volume of request DEA-Controlled Substance #1
Please note that there may be a minimum volume required to obtain, given the size of the vial/bottle provided by manufacturer (For example, Ketamine (100mg/ml) comes in a minimum volume of 10mL).
Number of bottles/vials. for DEA-Controlled Substance #1
Please note that each lab is typically allowed up to two bottles/vials of a drug at a time.
Other notes for DEA-Controlled Substance #1
If needed, please provide as much detail as possible

DEA-Controlled Substance Request #2
Name of DEA-Controlled Substance #2 Requested
For buprenorphine, please indicate if either buprenorphine-sustained release (SR) or regular buprenorphine is requested. As previously mentioned, please note some drugs may take more than 5 days to fill, depending on its availability.
Other Drug not listed
Please provide as much detail as possible
Volume of request DEA-Controlled Substance #2
Please note that there may be a minimum volume required to obtain, given the size of the vial/bottle provided by manufacturer (For example, Ketamine (100mg/ml) comes in a minimum volume of 10mL).
Number of bottles/vials. for DEA-Controlled Substance #2
Please note that each lab is typically allowed up to two bottles/vials of a drug at a time.
Other notes for DEA-Controlled Substance #2
If needed, please provide as much detail as possible

DEA-Controlled Substance Request #3
Name of DEA-Controlled Substance #3 Requested
For buprenorphine, please indicate if either buprenorphine-sustained release (SR) or regular buprenorphine is requested. As previously mentioned, please note some drugs may take more than 5 days to fill, depending on its availability.
Other Drug not listed
Please provide as much detail as possible
Volume of request DEA-Controlled Substance #3
Please note that there may be a minimum volume required to obtain, given the size of the vial/bottle provided by manufacturer (For example, Ketamine (100mg/ml) comes in a minimum volume of 10mL).
Number of bottles/vials. for DEA-Controlled Substance #3
Please note that each lab is typically allowed up to two bottles/vials of a drug at a time.
Other notes for DEA-Controlled Substance #3
If needed, please provide as much detail as possible

By providing your name below and pressing submit, you indicate that you have read and understand the following statement:
I understand that I am responsible for the administration, storage, and accurate documentation of the dose and use of the drug/s requested as described in the approved protocol of the Principal Investigator named above. Controlled substances must be stored under double lock conditions, as required by federal regulations, and any unused or expired amount will be returned to Tufts CMS. Empty vials and associated drug logs of controlled substances will be returned to Tufts CMS for disposal.*

I have read and understand the above statement
Name of individual REQUESTING drug and/or supplies*

First NameLast Name
E-mail of individual REQUESTING drug(s)/supply(ies)*
example@example.com
Name of individual PICKING UP controlled substance(s)*

First NameLast Name
Direct phone number of individual PICKING UP controlled substance(s)*

Area CodePhone Number
Requested Pick Up Date
Investigators requesting drugs and other supplies should submit this form at least five business days prior to the date needed. (Note: Some special orders may take longer than 5 days to procure). This does not include University recognized holidays, bonus days, or weekends.
Should be Empty:

By providing your name below and pressing submit, you indicate that you have read and understand the following statement: