Page 1 Form Revised Dec 2016
WICHITA STATE UNIVERSITY
INSTITUTIONAL ANIMAL CARE AND USE COMMITTEE (IACUC)
FINAL REPORT FORM
Principal Investigator:
Protocol Title:
Protocol #: Date of Initial Approval:
Expiration Date: Animal Species:
1. RECORD OF ANIMAL USAGE OR IF TISSUE STUDY CLICK HERE AND SKIP TO #2
SPECIES
TOTAL #
APPROVED FOR
PROTOCOL
TOTAL #
USED FOR
PROTOCOL
TOTAL #
USED FOR
PAST YEAR
2. REQUEST PROTOCOL TERMINATION
A. Final Annual Report De Novo Review New Protocol #
B. Completed - no further activities with animals will be done.
C. Currently inactive - project initiated but project has not/will not be completed.
D. Inactive - project never initiated.
3. FINAL ANNUAL REPORT
Provide a brief update on the progress made in achieving the specific aims of the protocol. For animal studies,
please include in your answer how animals were utilized and how that fits with the total number of animals
approved for the protocol. Please provide an explanation for any large discrepancy between the number of animals
requested and those utilized. (If additional space is needed to provide a complete answer, please attach a
separate Word document with further information.)
Page 2 Form Revised Dec 2016
4. PROBLEMS/ADVERSE EVENTS
Describe any unanticipated adverse events, morbidity or mortality, the cause(s), if known, and how these problems
were resolved. If NONE, this should be indicated.
5. 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 of the Principal Investigator Date
Signature of IACUC Representative Date
**Completed forms should be submitted to IACUC@wichita.edu **
click to sign
signature
click to edit
click to sign
signature
click to edit
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome