Komparativ medicin
Individual Access Authorization to Animal Facilities
Requested main facility
The study will be performed in other animal facilities as well, name
Period from Until
Access applicant Ethical Permit Holder
Name: Name:
Phone: Phone:
E-mail: E-mail:
Department: Department:
A) Certification of Laboratory Animal Science
FELASA B certificate Authority: Date of Issue:
FELASA C certificate Authority: Date of Issue:
Equivalent certificate, type Authority: Date of Issue:
No, I do not have an approved certificate, fill in section B below
B) Competence evaluation (L150, 2012:26)
Which specie(s) have you worked with earlier?
Rodents Lagomorphs
Amphibians Others Techniques you feel
comfortable in performing.
Handling Biopsies
Blood sampling Injections
Euthanasia Other Other relevant information
Attached document for evaluation include
Curriculum Vitae (CV) with relevant list of publication Other, please describe
For a complete evaluation send this form and attachments to las-edu@km.ki.se
C) Assessment of allergy to laboratory animals
I have been informed about my right to be tested for allergy to rodents by Ethical Permit Holder
Other
I have not been informed about my right to be examined for allergy to rodents
I hereby ensure that the above information is correct and I am fully aware of that my access to the facility can be immediately suspended if I act in conflict with the law or local rules.
Signature Applicant Signature Ethical Permit holder
Date Date
Version: 2016-05-12
Select animal facility
To be filled in at the Animal Facility
Applicant
D) Education control
The applicant has relevant education according to the rules and legislations.
Centuri KOMP nr
E) Introduction
Introduction to animal facility by facility representative, according to checklist.
Centuri KI nr
Signature introducer
Date
In prints
E) Access approved
Starting point of entrance permission Access type
Signature access administrator
Date
In prints
I have actively taken part in the introduction and carefully read and understood the
instructions concerning work with laboratory animals at the requested animal facility. I am aware that the access card is personal and are not to be lent to any another person.
Signature Approved Super Intendant Signature Access holder
In prints In prints
Date Date
