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Administrative (Non-Clinical) Policy
This administrative policy applies to the operations and staff of the University of Wisconsin Hospitals and
Clinics Authority as integrated effective July 1, 2015, including the legacy operations and staff of UWHC
Policy Title: Handling of Animals for Treatment or Research
Policy Number: 12.33
Effective Date: January 1, 2016
Chapter: Environmental Safety
To ensure that proper procedures are followed when animals are treated or animal research is being
conducted in the UW Health facilities.
A. UW Health facilities are not designated for animal treatment or research, but an exception to this
policy can be granted.
B. Approval of the Director of Life Safety must be obtained at least four weeks before any animals
are brought into UW Health patient care areas for research, diagnosis or treatment.
C. The Director of Life Safety may deny requests to allow animals into patient care areas or to use
patient care equipment without providing justification to the requester.
D. Animal subjects brought into UW Health facilities for treatment or research purposes must be
separated from human patients at all times.
E. The use of invasive patient care instrumentation on animals is strictly prohibited.
A. No patient care area is designated for animal research or treatment.
B. Special permission from the Director of Life Safety is necessary if a physician or researcher
wishes to have an animal in any area not specifically designated for animals.
1. Requests are to be made in writing to the Director of Life Safety or designee via email.
Requests must include:
a. The species of animal involved
b. Explanation of the procedure and the specific patient care equipment to be used
c. Desired date(s)
d. Reason for procedure being done at UW Health facilities
e. Time of the procedure
f. Individual responsible for the procedure
2. Four weeks advance request is required to ensure that proper preparation activities can be
completed should the Director of Life Safety give approval.
3. If similar clinical equipment which is designated for animal use is available in reasonably
accessible locations (e.g., at the School of Veterinary Medicine or campus facilities),
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permission to use this equipment should be exhausted before seeking permission to use
UW Health equipment.
4. The Director of Life Safety or designee will discuss the request with the administrator of
the area involved. To ensure proper protection and clean up procedures, the Director of
Life Safety will also confer with the Infection Control Practitioner and the Director of the
Animal Resource Center.
5. If questions arise regarding potential risk of infection that the animal(s) may pose, the
Infection Control Practitioner on call, in consultation with the Hospital Epidemiologist,
will be the final arbiter of whether the proposed use of UW Health clinical equipment or
clinical space is acceptable.
6. The decision to permit animal entry into UW Health may take into account availability of
diagnostic or therapeutic instrumentation at other locations (e.g., School of Veterinary
Medicine), potential infection risk to patients, competency of research staff to operate and
maintain clinical instruments and to adequately disinfect such equipment, aesthetics (e.g.,
animal odors) or impact on public perception.
7. The Director of Life Safety is not required to provide justification of denied requests.
8. Permission for animal research in UW Health facilities may be removed for non-
compliance with this policy or because of changing patient needs.
C. If approval is given, the Director of Life Safety will provide, in writing, stipulations that must be
adhered to by staff handling animals. These may include:
1. Limitations on times that animals may be present in clinical areas.
2. Precautions for transport of animals (e.g., animal must be in a covered carrier).
3. Specific routes of arrival and departure to minimize contact with patients and visitors.
4. Additional precautions for use of clinical areas (e.g., clean sheet must be placed on MRI
table to prevent direct contact of animal with surface; plastic bags must be used to cover
and protect instruments from contamination, etc.)
5. Decontamination requirements (e.g. research staff must disinfect surfaces after use,
research staff must carry disinfectant and cleaning materials to clean up spills or animal
6. Contact numbers should questions arise, or unexpected problems occur.
D. Additional Coordination needs
1. If the request concerns a patient treatment area, the requester must arrange with the area
manager for access to the area after normal working hours. Animals may not be brought
into a patient treatment area while patients are present. It will be the responsibility of the
investigator to ensure that no patients are in the area when the animal is present.
2. Research funds must be allocated to meet the costs incurred in providing the services in a
patient treatment area. Arrangements for billing should be coordinated with the
3. Coordination must be made with the Department of Environmental Services to schedule
terminal cleaning following the animal procedure. The department in which the
procedure will take place must make these arrangements. The requesting department
should contact 263-1255 to make arrangements with Environmental Services.
Sr. Management Sponsor: VP, Facilities and Support Services
Author: Director of Life Safety
Reviewer: SVP, Assoc. Chief Medical Officer
Approval Committee(s): Environment of Care Safety Committee, UW Health Administrative Policy and
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President, University of Wisconsin Hospitals
Chief of Clinical Operations
Previous revision: 012013
Next revision: 012019