ࡱ> TVSg bjbj`` .H x\ x\  ,,,,H, JLPPPP+++       $"%7 +++++7 PPL aaa+PP a+ aa:Q,PPAA } b 0 R@&K@&@&$++a+++++7 7 a+++ ++++@&+++++++++ > : CONTROLLED SUBSTANCE PROTOCOL REVIEW FORM OLD DOMINION UNIVERSITY Directions: Researchers planning to use controlled substances as part of their research must complete this form. Researchers must have a current DEA license and VBP Registration. This form should be returned to the Office of Research, attn: Research Compliance. Research Compliance will review the application and contact the applicant if there are any questions or concerns. The applicant will receive confirmation to proceed with the project. Administrative InformationName of ResearcherType of Application Initial Application Renewal Application AmendmentDepartmentCampus AddressOffice PhoneEmergency/After Hours PhoneFaxEmailTitle of Research or Teaching Project Please list all personnel authorized to work with controlled substances under your supervision. Proposed Starting DateGrant Number (if applicable)Does the research involve the administration of drugs to live animals? Yes No If yes, has the project been reviewed by the IACUC? Yes (indicate the protocol number) NoDoes the research involve the administration of drugs to human subjects? Yes No If yes, has the project been reviewed by the IRB? Yes (indicate the protocol number) NoControlled SubstancesCurrent DEA license expiration dateCurrent VBP registration expiration dateList the name(s) and amount(s) of controlled substance(s) to be used in the research project. Which controlled substance schedule(s) are you planning to use? (Please check all that apply)  FORMCHECKBOX  I  FORMCHECKBOX  II  FORMCHECKBOX  III  FORMCHECKBOX  IV  FORMCHECKBOX  V  FORMCHECKBOX  VIWhere will the controlled substances be stored? (Please include building name(s) and room number(s)). Describe security measures to prevent theft or loss of controlled substances. Is a securely locked, substantially constructed cabinet used for storage of controlled substances? Yes No Where will the controlled substances be used? (Please include building name(s) and room number(s)). Describe security measures to prevent theft or loss of controlled substances during use. Describe the proposed use(s) of the controlled substance in research. Please include the number and species of research subjects, dose to be administered, the route and method of administration, and duration of the project. (Attach an extra sheet if necessary.) 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