Fillable IACUC Application For On-site Research Or Teaching

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IACUC Application For On-site Research Or Teaching

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The IACUC Application For On-site Research Or Teaching form is 6 pages long and contains:

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  • 0 check-boxes
  • 53 other fields

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File type: PDF

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APPLICATION TO USE LIVE VERTEBRATE ANIMALS in
On-Site Research or Teaching
Arkansas Tech University
Institutional Animal Care and Use Committee (IACUC)
OFFICE USE ONLY
Protocol Number: ______________
Approval period:
____________ _____________
From To
Approval may be up to 3 years
Principal Investigator (PI) NAME(s): DEPT:
____________________________________ ___________________________________
____________________________________ ___________________________________
____________________________________ ___________________________________
WORK PHONE: EMAIL:
____________________________________ ___________________________________
____________________________________ ___________________________________
____________________________________ ___________________________________
TITLE OF PROJECT/ BUDGET NAME (assigned by ATU Budget Office if applicable):
TYPE OF PROJECT (please check one): ___ Research ___ Teaching/training ___
Collection/Banking
All five major sections of the application must be completed within the form field provided.
If some portion of a section of this application does not apply to your project, please indicate as not
applicable (NA).
If attachments are necessary to provide a response to a specific section, or portion thereof, the attachment
must be clearly referenced under the appropriate section and the section number noted on the attachment.
If the investigator has a question about the completion of this form, please contact the ATU IACUC Office for
clarification via the Office of Sponsored Programs and University Initiatives (880-4329 or email
IACUC@atu.edu).
SECTION 1: PROJECT RELEVANCE
1.1 Please provide a brief synopsis of the project including the rationale to support its
objectives (e.g. intended benefits to humans, animals and/or the advancement of scientific knowledge).
This section should be understandable to a general reader and focus on the big picture.
Note: More detail on the specific types and numbers of animals will follow in section 2; types of procedures
and effects on animals in section 3; safety concerns for humans in section 4; and finally, on-campus
approvals are in section 5 at the end.
APPLICATION TO USE LIVE VERTEBRATE ANIMALS in
On-Site Research or Teaching
Arkansas Tech University
Institutional Animal Care and Use Committee (IACUC)
OFFICE USE ONLY
Protocol Number: ______________
Approval period:
____________ _____________
From To
Approval may be up to 3 years
1.2 Clearly articulate the specific justification for the use of live vertebrate animals to explain
why the project objectives cannot be accomplished using an alternative model (e.g. in
vitro, computational model/simulation, invertebrate animals, or other).
SECTION 2: ANIMALS
2.1 Please indicate the total number of animals to be used; including species (or group),
ages, sex.
2.2 If dogs or cats are to be used, please specify the source of the animals.
APPLICATION TO USE LIVE VERTEBRATE ANIMALS in
On-Site Research or Teaching
Arkansas Tech University
Institutional Animal Care and Use Committee (IACUC)
OFFICE USE ONLY
Protocol Number: ______________
Approval period:
____________ _____________
From To
Approval may be up to 3 years
SECTION 3: ANIMAL PROCEDURES
3.1 Please provide a list of specific procedures that involve the use of animals in this project.
Where appropriate, this section should clearly identify specific procedures intended to
minimize pain such as anesthetic, analgesic or tranquilizing drug application. Note: an
annual report of the actual number of animals collected by species must be provided to the IACUC.
3.2 Check which of the following pain categories applies to the procedures to be used on
animals in this project. Note: letter designations correspond to the eventual USDA report; where A and
F are reserved to report the numbers, types, and totals of affected animals.
____ B – animals collected and bred/held as part of the project
____ C – procedures will cause no (or minimal) pain or distress (e.g. identification
and measurements, injections, blood sampling, tattooing, electrofishing, live-trapping,
netting, marking by fin-clip or toe-clip, health assessments,…)
____ D – procedures involve pain or distress but anesthetics or tranquilizing
drugs are used
____ E* – procedures involve pain or distress and no anesthetic, analgesic or
tranquilizing drugs can be used (e.g. leg-hold traps, confinement in adverse
environments, or procedures with death as an endpoint, like rotenone sampling for fish)
* If any category “E” procedures will be performed, you must complete sub-section 3.3 below and 3.4 if
applicable.
3.3 Justification for special circumstances (USDA pain category “E” procedures only).
Projects involving USDA pain category “E” procedures require specific scientific
justification of why the procedure is necessary without mitigation.
APPLICATION TO USE LIVE VERTEBRATE ANIMALS in
On-Site Research or Teaching
Arkansas Tech University
Institutional Animal Care and Use Committee (IACUC)
OFFICE USE ONLY
Protocol Number: ______________
Approval period:
____________ _____________
From To
Approval may be up to 3 years
3.4 Euthanasia. Describe the final disposition of the animals used in the project. If
euthanasia is planned, state whether the method of euthanasia is consistent with the
recommendations of the American Veterinary Medical Association (AVMA) Guidelines
for the Euthanasia of Animals (link available at the end of this document). If not, describe
the method and provide a scientific justification for the deviation.
3.5 Please indicate the site(s) where the procedures will be performed.
SECTION 4: SAFETY
4.1 What human safety issues are peculiar to the type(s) of animal procedures,
collection, handling, and/or holding proposed for this project? Briefly describe your
plans to minimize risks.
APPLICATION TO USE LIVE VERTEBRATE ANIMALS in
On-Site Research or Teaching
Arkansas Tech University
Institutional Animal Care and Use Committee (IACUC)
OFFICE USE ONLY
Protocol Number: ______________
Approval period:
____________ _____________
From To
Approval may be up to 3 years
4.2 Will your work involve hazardous materials, objects, equipment or activities other
than above? If so, list associated specific training modules that will be completed by
any personnel involved in those procedures (see module list and associated training
links available through http://www.atu.edu/physci/training.php ) Alternatively, specify
other required safety training.
SECTION 5: APPROVALS
5.1 Principal Investigator acknowledgement of familiarity with the IACUC process,
responsibility for appropriately training all personnel who will handle animals in this project, and
assertion that this document is submitted in good faith as part of that process (add rows as
needed for co-PI’s):
__________________ _____________________________________ ______________
Name Signature Date signed
Principle Investigator
5.2 Departmental approval (only needed if using Departmental budget):
If animals will be used in teaching or training or if the animal research will be supported by
departmental or other non-regulated funding, departmental approval is required before IACUC
approval may be granted. If the Departmental Chair is also an investigator on the protocol, this
approval must be obtained from the next highest level of administrative authority not involved in the
project.
“I have read the Application to Use Animals, and find this research to be appropriate in design and that
the investigator (or faculty sponsor) is competent to perform (or supervise) this study. My signature
below denotes departmental approval of this study as submitted.”
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APPLICATION TO USE LIVE VERTEBRATE ANIMALS in
On-Site Research or Teaching
Arkansas Tech University
Institutional Animal Care and Use Committee (IACUC)
OFFICE USE ONLY
Protocol Number: ______________
Approval period:
____________ _____________
From To
Approval may be up to 3 years
____________________ _____________________________________ ______________
Name Signature Date signed
Department Chair
5.3 ATU IACUC approval:
_Alvin Williams, D.V.M.__ _____________________________________ ______________
Name Signature Date signed
Chair, ATU IACUC
Resources:
Sources: guidance and technical terminology in this document are largely from these sources, but any errors
or deficiencies are the responsibility of TECH’s IACUC which is overseen by the Office of Academic Affairs.
A link to NIH Office of Laboratory Animal Welfare - Vertebrate Animals Section
http://grants.nih.gov/grants/olaw/vertebrate_animal_section.htm
American Veterinary Medical Association (AVMA) Guidelines for the Euthanasia of Animals
https://www.avma.org/KB/Policies/Documents/euthanasia.pdf
Example of UDSA report that will eventually go from the ATU-IACUC to the USDA to indicate format.
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IACUC Application For On-site Research Or Teaching

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Completed 16 March 2020

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