WICHITA STATE UNIVERSITY
INSTITUTIONAL ANIMAL CARE AND USE COMMITTEE (IACUC)
ANNUAL ANIMAL TISSUE REVIEW FORM
Project Description Utilizing Animal Tissues but Not Live Animals
Date:
Principal Investigator:
Protocol Title:
Protocol #:
Funding Source:
Date of Initial Approval:
Expiration Date (for this reporting period):
Animal species tissue(s) to be utilized:
1. Protocol Status
A. Active - project ongoing
B. Currently inactive - project was initiated but is presently inactive.
C. Inactive - project never initiated but anticipated start date is:
2. Source of animal material: (List the name(s) of the sources of the animal tissues, for
example Yoder Meats, Yoder, KS. If coming from another approved protocol, please list the
protocol #.)
3. Project Personnel: Please list all personnel working on this project
Name and Highest Degree
Role/Responsibility for Project
Page 2 Form Revised Dec 2016
3a. Are you requesting to add any new personnel at this time?
No, skip to #4.
Yes, please complete the below box.
Name and
Highest Degree
Title
(Faculty,
Student)
Relevant Experience
Role/Responsibility for
this project
4. Progress Report. If the status of this project is 1.A. (Active; project ongoing) or 1.B. (Project
was initiated, but is presently inactive), provide a brief update on the progress made in
achieving the specific aims of the protocol.
5. Future Plans
No changes are planned; the project will continue as previously approved by the IACUC.
Changes are planned. (Submit an amendment describing proposed changes. Please note
that if the modifications are significant, you may be required to complete a new application.
If you have questions or require assistance in making this determination, please contact the
IACUC Chairperson and/or the Attending Veterinarian.)
Other, explain:
Page 3 Form Revised Dec 2016
CERTIFICATION OF THE PRINCIPAL INVESTIGATOR. Signature certifies that the Principal
Investigator understands the requirements of the PHS Policy on Humane Care and Use of Laboratory
Animals, applicable USDA regulations and the Institution’s policies governing the use of vertebrate
animals for research, testing, teaching or demonstration purposes. Signature further certifies that the
investigator will continue to conduct the project in full compliance with the aforementioned
requirements.
Signature of the Principal Investigator Date
Signature of IACUC Representative Date
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