Ethiqa XR® Administration Request Form

Ethiqa XR (buprenorphine extended-release) provides 72 hours of analgesia for mice and rats in a single injection. The ARC offers administration of this drug on a fee-for-service basis for investigators who have Ethiqa approved on an animal use protocol, but whose research needs do not warrant purchasing their own supply of Ethiqa XR. Please see the linked document for details on the logistics of the request process.

For more information regarding the appropriateness of Ethiqa XR for your specific study, please see the Ethiqa website, the Ethiqa product insert, or contact ARC vet staff directly.

Please submit this form at least 7 business days ahead of the requested Ethiqa administration date.

Study Information

Principal Investigator

IACUC Protocol Number

UT Account to Bill to

Contact Information

* List someone that the ARC vet staff can reach on the day of surgery.

Day-of-Surgery Contact Person

Phone Number

Is the person submitting this form different from the above contact?

Yes

Submitter

Submitter Phone Number

Submitter Email

Procedure Information

Date of Surgery

Approx. Start Time of Surgery

Name of Surgery

Please attest that buprenorphine extended-release or sustained-release (e.g. Ethiqa) is approved in the IACUC protocol for this procedure.

Yes

Animal Information

Species:

Mouse

Rat

Housing Location

Building

Room(s)

Rack(s)

Total Number of Cages Receiving Ethiqa

Total Number of Animals Receiving Ethiqa

Any other helpful information regarding animal locations?