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WICHITA STATE UNIVERSITY INSTITUTIONAL ANIMAL CARE AND USE (Wichita State University)

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Page 1 Form Revised April 2018
WICHITA STATE UNIVERSITY
INSTITUTIONAL ANIMAL CARE AND USE COMMITTEE (IACUC)
ANIMAL TISSUE FORM
This abbreviated form is to be complete for research projects that utilize animal parts but do not actually require the use of
“live” animals. For example, projects that utilize material from slaughterhouses or local farms would employ this article.
This exercise is intended to allow the WSU IACUC to maintain knowledge of all animal-related research on the campus.
Date:
Principal Investigator:
Co-Investigator Name(s) and Titles (faculty, grad student, etc):
Project Title:
Protocol #:
Funding source:
Anticipated Start Date: Anticipated End Date:
1. Species and tissue(s) to be utilized:
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 number.)
3. Provide brief description of disposal methods for animal tissues.
Page 2 Form Revised April 2018
4. Provide a description of the use of the material in your research:
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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WICHITA STATE UNIVERSITY INSTITUTIONAL ANIMAL CARE AND USE (Wichita State University)

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Completed 25 July 2020

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