Fillable IACUC Cover Sheet

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IACUC Cover Sheet

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ADMINISTRATIVE COVER SHEET FOR AN APPLICATION
TO USE LIVE VERTEBRATE ANIMALS IN RESEARCH OR TEACHING
Arkansas Tech University
Institutional Animal Care and Use Committee (IACUC)
TO BE COMPLETED BY THE APPLICANT
Is the application eligible for an expedited review under USDA guidelines? (If USDA
pain category D or E applies to the project as notated on item 3.2 of the application, the
application is not eligible for expedited review). If eligible, please justify the need for the
expedited review on item 8 of the cover sheet.
___ Yes ___ No
Please submit this form electronically as a single .pdf document to the IACUC e-mail.
Also submit as a separate single .pdf, the respective application relative to one of the last
three categories checked immediately below. Both attachments go to IACUC@atu.edu.
(paper submissions will not be accepted)
Check one: New Application for Research
New Application for Teaching (which will be issued for a three year period).
3 Year Renewal for Research or Teaching - Highlight any modifications to
procedures when completing the new application. Please provide the previously
assigned IACUC protocol number here ___________________
Agricultural (Agricultural Source/Use) Also Submit Associated Application
Field (Field Sampling or Wild/Feral Source/Use) Also Submit Associated Application
On-Site (Captive Animal Source/Use) Also Submit Associated Application
FOR OFFICE USE ONLY
IACUC PROTOCOL NUMBER: ________________________________________
IACUC Approval has been granted for the project described in this document
Original Approval Date: ____________________________________
Approval Period: ________________ ________________
From To
1. TITLE OF PROJECT: _______________________________________________________
____________________________________________________________________________
2. PRINCIPAL INVESTIGATOR(PI) INFORMATION: (If not an ATU faculty, include an ATU
faculty sponsor, see question # 5)
PI Name: ___________________________ Department: ________________________
Work Address: _______________________________________________________________
____________________________________________________________________________
Work Phone: _______________________ Emergency Phone (after Hours): _______
Cell Phone: ________________________ Fax Number: _______________________
E- Mail Address: _____________________________________________________________
3. CO- INVESTIGATOR(CI) INFORMATION: (If not an ATU faculty, include an ATU faculty
sponsor, see question # 5)
N/A ___
CI Name: ___________________________ Department: ________________________
Work Address: _______________________________________________________________
____________________________________________________________________________
Work Phone: ________________________ Emergency Phone (after Hours): _______
Cell Phone: _________________________ Fax Number: _______________________
E- Mail Address: _____________________________________________________________
4. CONTACT PERSONFOR PAPAERWORK ISSUES: (If other than PI)
N/A ___
Name: _____________________________ Department: ________________________
Work Address: _______________________________________________________________
____________________________________________________________________________
Work Phone: _______________________ Emergency Phone (after Hours): _______
Cell Phone: ________________________ Fax Number: _______________________
E- Mail Address: _____________________________________________________________
5. ATU FACULTY SPONSOR: (required if PI is not an ATU faculty)
N/A ___
PI Name: ___________________________ Department: ________________________
Work Address: _______________________________________________________________
____________________________________________________________________________
Work Phone: _______________________ Emergency Phone (after Hours): _______
Cell Phone: ________________________ Fax Number: _______________________
E- Mail Address: _____________________________________________________________
6. QUALIFICATION AND TRAINING OF PERSONNEL:
Qualification of the PI(s): ___ PhD
___ MS
___ BS
___ Other (explain)
Training:
The PI must approve or oversee the qualifications, training, and safety of all personnel
who will be handling animals associated with this project. Please list any additional
training required for this project.
7. FUNDING (Describe all funds you plan to apply for, have pending, or have received)
___ Intramural Funding: (e.g. Departmental funds, Undergraduate Research Funds, personal
funds, donors/gifts, etc.) Please list all ATU identification numbers of funding if applicable.
___ Extramural Funding: (if applicable, include ATU budget titles and codes)
8. EXPEDITED REVIEW
If the application is eligible, please justify the need for an expedited review (e.g. pending grant
proposal).
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IACUC Cover Sheet

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Completed 16 March 2020

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