Institutional Animal Care and use Committee (IACUC)
Office of Regulatory & Research Compliance (ORRC)
University at Albany, MSC 309
(Phone) 518-437-3850 (Fax) 518-437-3855 (E-mail) iacuc@albany.edu
Date Received
ORRC Assigned : JG ___ TR ___
AB___
Date: _______________
Submission #
Date of determination: ________________
INSTITUTIONAL ANIMAL CARE AND USE COMMITTEE (IACUC)
CONTINUATION FORM
11.01.13
General Information
1.1 PI information
Protocol #
-
Protocol Title
Expiration Date:
Name of PI
Department
Campus address
E-mail Address
Phone
Fax
Faculty
Undergraduate
PI Level
Status of the activities
proposed in this
protocol
Postdoctoral
Other : (
Graduate student
)
A. Active - project ongoing.
B. Currently inactive - project was initiated but is presently inactive.
C. Inactive - project never initiated but anticipated start date is
Co-PI information
Protocol #
-
Protocol Title
Name of PI
Department
Campus address
E-mail Address
Phone
Fax
Co-PI Level
Faculty
Undergraduate
Postdoctoral
Other : (
Graduate student
)
Faculty Advisor Information
*If the principal investigator is a student, list name, department and local telephone and campus address of faculty
supervisor.
Name
Department
Campus address
E-mail Address
Phone
Fax
1-2. Request Protocol Continuance
A. Active - project ongoing. [→After this page, go to section3 (Skip section2)]
B. Currently inactive - project was initiated but is presently inactive.
[→Go to section 2 to provide detailed information]
C. Inactive - project never initiated but anticipated start date is
[→Go to section 2 to provide detailed information]
D. Inactive - project never initiated.
[→Skip the rest of form, submit “Study Closure Form”(Available our website: IACUC form section)”]
E. Currently inactive - project initiated but project has not/will not be completed.
[→After this page, go to section3 (Skip section2)]
F. Completed - no further activities with animals will be done.
[→After this page, go to section3 (Skip section2), and submit “Study Closure Form”(Available on our website: IACUC
form section)”)]
1-3. FUNDING SOURCE: Specify the funding source if applicable. If any source is new or if there were any
changes in previously submitted funding information, provide a copy of the relevant sections of the grant application
for review.
Funding information: (Agency)
(Funding date):
New?
Yes
No
1-4. PROJECT PERSONNEL.
Have there been any personnel/staff changes since the last IACUC approval was granted?
Yes
No
If yes, provide new personnel information using the Addition/Deletion of Study Personnel form.
Section 2. Request for Continuance

If any changes are planned, you must submit an IACUC Modification Request Form and any appropriate
Supplemental Forms available on the Regulatory & Research Compliance website at
http://www.albany.edu/research/compliance/Forms.htm. Under IACUC forms, see Additional IACUC Forms.
2-1. Request for Continuation. Please indicate the status of this project.
Continue with minor changes.
Continue with major changes.
If you check either box above, provide following information.
All others, skip this section and go to section 3.
2-2.
Changes in the protocol:
Have there been changes/additions in any of the following which are NOT described in the
approved protocol or an amendment? (Check all applicable items.)
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Euthanasia
Funding source
Condition (Sex
And/or age) of
animals
Numbers of animals
Species, strain or Genotype
Surgical Procedures
Source or method of
Animal Acquisition
Anesthesia/Analgesia
Blood/Tissue
Collection
Behavioral testing
procedure
Pain and Distress
Breeding Colony
Drug administration
Bio-toxic use
Other (specify;
2-3.
Experimental Site Change
)
JUSTIFICATION FOR CHANGES. Provide brief explanation for your requested change; Objectives must be
described in clear and short statement (DO NOT EXCEED 500 words):
Section 3. Progress Report
3-1. NATURE OF THE PROTOCOL/STUDY.
Please indicate the nature of this project. (Check all applicable items).
Chronic Study (Survival)
Acute Study (Acute)
Tissue/ Cell Study
Inducement of a Disease State
[PHYSICAL]
Inducement of a Disease State
[MENTAL/BEHAVIORAL]
Inducement of
Behavioral Stress/ Pain
Tail Snip
Single Behavioral Testing
Multiple Behavioral Testing
Single Surgery Procedure
Multiple surgery Procedure
Blood/Tissue Collection
Prolonged Restraint
Prolonged Food/Water deprivation
Shock Stimuli Involved
Controlled Substance
Bio-toxic Administration
Neuromuscular Blockers
Antibody Production
Other
Administration
Transgenic Breeding
3-2. RECORD OF ANNUAL ANIMAL USAGE
Species
Sex
Age at
experiment
[Experimental Animal]
Total # Approved
# Used to Date
From
To
From
To
From
To
From
To
Task Completion
date
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3-3. RECORD OF ANNUAL BREEDING COLONY ANIMAL [Breeding Animal if applicable]
Species
Sex
Total #
Approved to
be breed
# of breeder pair
Total # of Annual of
production
(total number of
offspring in the colony)
From
To
From
To
From
To
# of offspring
utilized in the
project
3-4. Does this study involve pain and distress of animals? If yes, mark category:
Yes
No
[USDA] PROJECT (Pain) CATEGORY [ X ]:
C
D
E
3-5. Please provide the following written objectives; please note that objectives must be described in clear and
short statements (DO NOT EXCEED 500 words), and Descriptions must be written in language that is
understandable to a high school student.
PROGRESS REPORT. Provide a brief update on the progress made in achieving the specific aims of the protocol.
PROBLEMS/ADVERSE EVENTS. If the status of this project is Active (project ongoing) or Project was initiated,
but is presently inactive, 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. Objectives must be described in clear
and short statement:
DUPLICATION. Activities involving animals must not unnecessarily duplicate previous experiments. Provide written
assurance that the activities of this project remain in compliance with the requirement that there must be no
unnecessary duplication; Objectives must be described in clear and short statement (DO NOT EXCEED 500 words):
REFINEMENT. Alternatives to the use of animals should be considered and used when possible. Since the last IACUC
approval, have alternatives to the use of animals become available that could be substituted to achieve your specific
project aims?
YES
NO
Not applicable Reason:
Please provide 3 separate UPDATED search results.
those subjects must be included.
If your experiment involves pain and distress of animals,
The date ranges for each database search are also required. Please provide the following information for each
procedure. Duplicate the table as often as required. DO NOT attach print-outs of the searches.
Procedure:
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Databases searched (minimum of 3): e.g. medline, biosis, Agricola
Date search conducted:
Date range of search (month/year)
From:
To:
Keywords used:
Procedure:
Databases searched (minimum of 3): e.g. medline, biosis, Agricola
Date search conducted:
Date range of search (month/year)
From:
To:
Keywords used:
Procedure:
Databases searched (minimum of 3): e.g. medline, biosis, Agricola
Date search conducted:
Date range of search (month/year)
From:
To:
Keywords used:
PRINCIPAL INVESTIGATOR’S ASSURANCE STATEMENT
I agree to abide by the Public Health Service (PHS) policy, USDA Regulations, the University of Albany Standard
Operation Procedures, the Guide for the Care and Use of Laboratory Animals, the Animal Welfare Act (AWA), all federal,
state and local laws and regulations and policies of the University of Albany.
Principal Co-Principal Investigator Certification
_____________________________________________
Principal Investigator Signature
Date:
Printed Name:
_____________________________________________
Co-Principal Investigator Signature
Date:
Printed Name:
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University at Albany Veterinarian Certification
I have consulted with Principal Investigator and certify that:
1) all members of the research team involved in the care and use of animals have completed the
required occupational safety and health program requirements; and
2) all painful procedures have been reviewed for the proper use of anesthetics and pain-relieving
medications.
_____________________________________________
Veterinarian Signature
Date:
Antigone McKenna, DVM
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