Fillable Southeastern Louisiana University - Protocol Annual Update/Amendment/Extension Form

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Southeastern Louisiana University - Protocol Annual Update/Amendment/Extension Form

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April 2009 version
1
Southeastern Louisiana University
Institutional Animal Care and Use Committee
Protocol Annual Update / Amendment / Extension Form
Protocol Title:
Primary Investigator:
IACUC Protocol#:
1. This form is being used for: (Check all that apply.)
Annual Update (e.g., yearly collection permits/licenses)
Protocol Amendment (minor change in existing project/experiment)
Protocol Addition (addition of new project/experiment to existing protocol; if new project is extensive,
IACUC may request a new protocol.)
Extension of Protocol termination date (6 month maximum)
2. Review original protocol and explain changes in the categories checked below: (Note: As part of this process,
IACUC will review the original protocol and, if substantial changes are noted, IACUC may require submission
of a new protocol.)
There have been no changes.
Changes in named personnel.
Persons deleted:
Persons added:
Answer the following for each individual added:
a. Person has completed animal on line-training and quiz. Yes No
b. Procedure(s) this person will perform:
c. Species on which this person will perform stated procedure(s):
d. How was (will) this individual (be) trained to do the procedure(s)?
e. Who (will) provide(d) the training?
f. Qualifications of this person to perform the procedure(s) and provide training?
(Years previous experience and training)
April 2009 version
2
Changes in experimental procedures performed on animals (including site and method of confinement and
restraint.) Describe and give reason(s):
___ Changes in agents or methods used to produce analgesia, anesthesia, or euthanasia. Describe and give
reason(s):
Changes in numbers of animals used. (See original protocol for description of Categories. You cannot
use more animals in this study than the number approved by the IACUC.)
original numbers requested change (+ or -) new totals:
Category A
Category B1
Category B2
Category C1
Category C2
*Category D
TOTAL
Justify Change(s):
Note: Any increase in total number of animals exceeding 50% of the original total number of animals may require
submission of a new protocol form rather than an amendment.
April 2009 version
3
___ Changes in sponsor (funding agency). Describe:
Changes in termination date. (Note: long-term holding of animals not undergoing experimental or
teaching procedures is not considered proper use of animals.)
Original termination date: Requested new termination date:
Reason(s):
___ Any other changes, not included above, that alter the use and care of animals in your study.
Explain:
(In signing this, I attest that the animals covered by this protocol have not experienced more discomfort or pain than that
which was stated in the original protocol, or as amended here, or in a previous form.)
_________________________________
Signature of Primary Investigator Date
For IACUC Use:
History of Protocol:
Initial project dates: from to
Approved extensions: to to to
Annual Updates: 1st: , 2nd:
Amendment: 1st: , 2nd: , 3rd: ,
4th: , 5th:
_____________________________
Chairman, Institutional Animal Care and Use Committee Date
_____________________________
University Veterinarian Date
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Southeastern Louisiana University - Protocol Annual UpdateAmendmentExtension Form

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Completed 30 May 2020

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