Stanford School of Medicine
Comparative Medicine–

Request for Euthanasia of Animals

Before animals can be disposed of, all sections of this form must be completed. In addition, please place green "EUTHANASIA" tape on cage cards of animal(s) to be euthanized. Do NOT remove cage cards. Animals are not to be consolidated with animals from other cages nor overcrowded prior to euthanasia, and must have access to food and water. Please refer to the current service rate schedule for the Department of Comparative Medicine for euthanasia charges. 


Investigator:                  Date:  
   
Department:                    APLAC#:  
   
Phone:                    Fax:  
    
Request for Comparative Medicine to Euthanize:   
Species:                  Animal ID#:  
   
Building and Room #:  
   
Method of euthanasia as described in APLAC protocol:  
   
Special Instructions:  
     
Can this animal be used for the tissue bank?
         Yes  No    
 If yes, has animal been utilized in any research
 project?     Yes  No     
  If yes, briefly explain nature of project, what
  substances or organisms have been injected in
  the animal or what type of surgery was performed:
       

Authorized by:
Please do not write below this line - for staff use only 
Confirmed:                     Procedure Date:  
   
Euthanasia performed by:       Date:  
      
Charged:   Yes  No             
Initials:

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