ࡱ>  pbjbjVV ;t<<5j j 8tm\TN!|E"U"U"]#8$$D%$$D0Q&8$8$&&U"]#(((&XU"]#(&((FKU"@&#&j[T$0Tlta'tth*%>h%,(%$%*%*%*%%(d*%*%*%T&&&&t*%*%*%*%*%*%*%*%*%j s: Cover Page For Protocol Applications Principal Investigator/Instructor (must be an logo faculty member):Title:Department:E-Mail:Campus Address:Phone:Purpose:Protocol Type: FORMCHECKBOX Research FORMCHECKBOX Instruction FORMCHECKBOX Other, specifyApplication Type: FORMCHECKBOX New Application FORMCHECKBOX Revised Application FORMCHECKBOX Continuation ReviewProject/Course Number: Project/Course TitleProject/Course Period:From:To:For projects beyond a 12-month period, the PI must submit a continuation review protocol and receive approval prior to the next period.Funding Source/Agency:Assurances & Authorizations:As principal investigator/instructor, I hereby assure that: Regulations: I am familiar with the Guide for the Care and Use of Laboratory Animals. Animal Use: The animals authorized for use in this protocol will be used only in the activities and in the manner described herein, unless a deviation is specifically approved by the IACUC. The animals living conditions are appropriate and medical care is available for these animals. Alternatives/Duplication: I have made a reasonable, good faith effort to find and utilize alternatives and refinements to these procedures and to avoid unnecessary duplication of previous experiments, unwarranted animal use, and unnecessary painful procedures. Statistical Assurance: I assure that there has been adequate evaluation of the statistical design or strategy of this proposal, and that the minimum number of animals needed for scientific validity are used. Occupational Health: I have taken into consideration and have made the proper arrangements regarding all applicable rules and regulations regarding zoonotic diseases, anesthetic safety, radiation safety, biosafety, recombinant issues, etc., in the preparation of this protocol. All logo employees with animal contact have received the guidelines - Occupational Health for Animal Care Workers and they are in compliance with this policy. Immunizations: Documentation of required tetanus and/or rabies immunizations is required. Attach appropriate documentation to the Form P or AP. Training: I verify that the personnel performing the animal procedures/manipulations described in this protocol are technically competent and have been properly trained to ensure that no unnecessary pain or distress will be caused as a result of the procedures/manipulations. Inexperienced personnel will be supervised. Permits/Licenses: I verify that I have obtained all appropriate permits and licenses to conduct the activities described in this protocol. Attach appropriate copies of the permits/licenses. A Curriculum Vita is required every three years. I verify that I have provided a current curriculum vita to the IACUC. Original date current vita submitted to IACUC _________________. Animal Use Records: I understand that records of these animal procedures must be maintained for a period of at least 3 years following the end of this protocol for inspection purposes. I understand the logo Institutional Animal Care and Use Committee and the attending veterinarian can enter the premises where these animals will be used or housed for the performance of official duties. I understand that this protocol and all relevant records shall be accessible for inspection and copying by authorized representatives of the U.S. Department of Health and Human Services (HHS), Public Health Service (PHS), Office of Laboratory Animal Welfare (OLAW) or other PHS representatives, the U.S. Department of Agriculture (USDA), Animal and Plant Health Inspection Service (APHIS), appropriate accrediting agencies, or the funding agency. The information provided is complete and correct to the best of my knowledge.Instructor Signature: Date:As Department Chairperson, I hereby acknowledge receipt of this protocol and approve its submission to the IACUC:Dept Chair Signature:Date:Dean Signature:Date:Protocol ReceivedProtocol NumberFORM A: DESCRIPTION OF ANIMAL USEDescribe the proposed course, its primary aims, the major reasons for using live animals, and detailed procedures to which the animals will be subjected. Include the species of animals to be used, the numbers to be used in each experimental/control group or procedure, and the name, doses and route of ALL drugs that will be administered to the animals. Detail animal to student ratio for each procedure. Also describe alternatives that are used in the course. Alternatives include methods that refine existing tests by minimizing animal distress, reduce the number of animals necessary for an experiment, or replace whole-animal use with in-vitro or other tests.  FORM B: PROCEDURES Complete a separate FORM B for each animal species used: Animal Species:#:Procedure:# Animals Used:Pain Code:Frequency:1234567891011121314151617181920For procedures requiring justification, attach FORM J: Justification of Discomfort, Distress, Pain.Drugs for alleviation of discomfort, distress, pain: (reference each procedure with its number)#:Drug:Dosage:Route:Frequency: FORM C: Animal Characteristics and Care (Complete a separate FORM C for each type of animal used.) Common Name:Strain:Sex:Age:Size:Source of animals:Rationale for selection of this species/strain:Number of Animals and Length of Residence:Total Number:Number on Hand at One Time:Average Length of Residence:Animal Housing and Use Facilities:Premises of housing (building and room #):Premises where procedures will be performed:Method of transportation & containment: Must conform to state and federal regulations if traveling on public roads or out of state. Animal Disposition:Disposition Method:For chemical euthanasia, indicate drug, dose, and route of administration:Identify the person authorized to perform euthanasia and/or disposal:Veterinary Care:Veterinarian consulted in the planning of painful procedures:Source of veterinary care for these animals:If the above named veterinarian(s) are not currently registered with the IACUC, please submit a professional vita with this protocol application.Multiple protocols:Will these animals be used for any other protocols?%NO%YESIf YES, indicate the additional protocols and justify: FORM J: Justification of Discomfort, Distress, Pain Fill out a separate form J for each procedure that falls within pain categories D and E Procedure:Species:The following information is required by USDA regulations to justify any procedures involving: Pain Category D - animals in which pain and distress during procedures was appropriately relieved by pain- or distress-relieving drugs; Pain Category E - animals involved in procedures which cause pain or distress that was not relieved by drugs for scientific reasons. List justifications for Pain Categories below. A detailed database search MUST be completed for alternatives on any procedures that fall into the pain categories listed above. Delineate methods and sources used in the search including database searched, date of search, period covered, and keywords used. A description on considerations of alternatives and determinations why they are not to be used must be provided. For Pain Category D, describe the use of the agent, dosage, route, and administration schedule. Also include the security and tracking of controlled drugs according to DEA requirements. (Cross Reference if these procedures were already outlined on FORM A.  FORM P: Personnel (Principal Investigator / Co-Investigator) (Complete a separate FORM P for each PI or co-PI involved in the handling and/or care of the animals for this protocol.) PI Name:Title/position:Department:Campus address:Campus phone:E-mail address:Protocol role:I am current on the following immunizations as appropriate:Immunization:Received:Date Received:Comment:Rabies FORMCHECKBOX Documentation of Rabies immunization required. Attach a copy to this form.Tetanus: FORMCHECKBOX Documentation of Tetanus immunization required. Attach a copy to this form.Hepatitis: FORMCHECKBOX Documentation of Hepatitis immunization required. Attach a copy to this form.Other (specify): FORMCHECKBOX Documentation of immunization required. Attach a copy to this form.Qualifications for my role in this protocol:As a PI or Co-PI in this protocol, I hereby assure that: I have received appropriate training in the handling and care of these animals and the procedures and techniques to be employed; I have received the guidelines: Occupational Health for Animal Care Workers and I am in compliance with this policy; I have read and understand the Guide for the Care and Use of Laboratory Animals; I understand that only those procedures explicitly detailed in this protocol may be performed on the animals in question and that unauthorized deviations from this protocol must be reported to the IACUC; and; I understand that documentation of all procedures performed on these animals must be maintained for at least 3 years after the end of the protocol for inspection purposes, and I understand the logo IACUC and Federal Regulations Regarding Noncompliance.Person:Signature:Date:PI or Co-PI: FORM AP: Associate Personnel (Undergraduate or Graduate Students, Technicians, Staff) Project/Course #:Project/Course Name:Principle Investigator(s): List of Associate Personnel who will be handling and/or caring for animals under this protocol:NameStatusRole in protocolGive date of last immunizationRabiesTetanusHepatitisDOCUMENTATION OF IMMUNIZATION IS REQUIRED. ATTACH COPIES OF APPROPRIATE RECORDS TO THIS FORM.As a PI or Co-PI of this protocol, I hereby assure that the above named associate personnel: is a complete listing of all associate personnel who will be handling and/or caring for animals under this protocol; have received appropriate training in the handling and care of these animals and the procedures and techniques to be employed; have received the guidelines: Occupational Health for Animal Care Workers and are in compliance with this policy; are familiar with the Guide for the Care and Use of Laboratory Animals; understand that only those procedures explicitly detailed in this protocol may be performed on the animals in question and that unauthorized deviations from this protocol must be reported to the IACUC; and understand that proper documentation of all procedures performed is mandatory.PersonSignatureDatePI or Co-PI: FORM S: Surgical ProceduresComplete a separate Form S for each major operative procedure that penetrates or exposes a body cavity, or causes impairment of physical or physiological function. Describe euthanasia procedures in non-survival surgery and management of ventilation if paralytic agents are used during surgery. Species:Procedure:Will more than one survival surgery be performed on an animal while on this study?%NO%YESIf YES, please justify.Surgery Location Room #:Post-op Care Room #:Surgeon:Pre-operative Procedures: Supportive Care During Surgery: Aseptic Methods: Post-operative Care: Post-operative Complication Management:  ANIMAL USE REPORT TO BE COMPLETED ON ALL APPROVED PROTOCOLS AND A CURRENT COPY KEPT IN THE ANIMAL HOLDING AREA Name:Protocol #:Project/Course Title:From:To: Species:Number Approved:(Please use a separate sheet for each species.)Note: An animal may be counted in more than one category; the column will not add up to equal the total number of animals approved on the protocol.Indicate the number of animals in each category below:Inspection Date ( / / )1. Number of animals carried over from previous protocol2. Number of new animals received3. Number of animals born on site4. Subtotal (add lines 1, 2, 3)5. Number of animals expired6. Number of animals euthanized7. Other disposition (Specify) 8. Subtotal (add lines 5, 6, 7)9. TOTAL NUMBER OF ANIMALS ON HAND (Subtract line 8 from line 4)10. Number of animals used11. Number of animals not usedPLEASE HAVE A CURRENT COPY OF THIS REPORT PER SPECIES AVAILABLE TO THE COMMITTEE AT THE INSPECTION SITE OR WHERE ANIMALS ARE HOUSED FOR THE SEMIANNUAL FACILITY INSPECTION. CONCLUSION REPORT CONCLUSION REPORT IS DUE 30 DAYS AFTER THE ENDING DATE OF THE PROJECT. SUBMIT REPORT TO THE IACUC, 328 Wells Hall. THE IACUC WILL NOT CONSIDER FOR REVIEW NEW PROTOCOLS OR RENEWALS FROM RESEARCHERS/INSTRUCTORS WHO FAIL TO COMPLY WITH THE ABOVE CONDITION. Name:Protocol #:Project/Course Title: From:To:Species:(Please use a separate sheet for each species.)Indicate the number of animals in each category below:Procedure # From FORM BTotal # of University Animals Used:Total # of Outside Animals Used:Pain Code:FrequencyAnimals used in multiple procedures? 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