Principal Investigator Name:
Department:

Building:
Room:
Campus Phone:
Email:

Individuals with Signature Authority

Please list all individuals who are authorized to sign for prescription drugs and veterinary supplies.

Drug Information

Please list all prescription drugs you plan to use. You are not required to list supplies such as sutures or drapes.

Drug Use in Research

(this information is to be kept on file as required by Florida Administrative Code 64F-12.023(2))

Title of Research Project or Protocol:
Brief Description of Research (2-3 sentences): Grant Number:

By submitting this form you indicate drugs will not be sold, traded or transferred to anyone directly involved in the specific research project for which the drug was obtained. Security and recordkeeping (of drug acquisition and disposition) will be maintained. These records will be audited by EH&S in accordance with the requirements of the EH&S Rx Drug Distributor – Health Care Entity license on which drugs are purchased.