The IACUC Office
University of Minnesota
Rev 12/12
CHANGE IN PROTOCOL
This document may be used to request any change to an approved IACUC protocol.
Minor changes will be reviewed by an RAR veterinarian; significant changes must be
reviewed by the IACUC through either the Designated Member Review or Full Committee
Review process. For guidance on Minor vs. Significant protocol changes, please view the
Protocol Amendments vs. Minor Changes:
PI:
Date:
PI E-mail:
Protocol #:
Species:
PI Phone:
Fax:
Please provide answers to the following questions (noting "not applicable" if your
requested change does not include this facet of your protocol).
1. Provide a brief summary of the currently approved animal activities on the protocol:
2. Provide a description of the desired change in animal activities including the
rationale/justification for the change:
3. If the change involves new experimental procedures, provide the rationale and a clear
description of the new experiments and/or procedures. Please note that if the procedures
being added are pain class B or C, you must submit an Appendix A:
4. If applicable, provide detail on any additional animals you will need as a part of this request
including group sizes and numbers justification. Please also complete the Animal Request
Table at the bottom of this document:
5. Provide details on potential study-induced or related adverse health conditions that might
occur as a result of this change, if any, and plans to address them:
6. List specific changes in anesthesia, analgesia, or euthanasia (type, dose, administration
method, etc.):
7. List included appendices, if any:
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The IACUC Office
University of Minnesota
Rev 12/12
8. Please note: If the proposed changes alter any safety procedures approved by the IBC, you
must notify the IBC via amendment request and obtain approval. If you are unsure or have
questions, please contact the IBC at 612-626-5654.
You may submit the Change in Protocol request from the Principal Investigator’s X500
email to IACUC@UMN.EDU If submitted via email, electronic submission of this form
from the PIs X.500 email address is considered legal documentation and confirmation
of his/her agreement to execute all activities as described.
or Print, Sign, and submit paper copy.
Animal Request Table
Number of Additional Animals Requested over Three-year
Period by Source
Pain
Number
Number to be Transferred2
Class1
Purchased
(one per (or received from From IACUC Number of
protocol #:
Animals
Common Name row) another institution)
1
Pain Classes
Number
Produced
In-house3
Number of Other
(Specify: clientowned, donated,
etc.)
Total
Number
 (in link - scroll to section 2.36, pg 31)
Class A: No pain, distress or use of pain-relieving drugs.
Class B: Potential pain/distress WITH appropriate analgesia/anesthesia/tranquilizers.
Class C: Pain/distress WITHOUT analgesia/anesthesia/tranquilizers.
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Number Transferred - Report the IACUC Protocol Number from which the animals will be transferred
(ex. 0802A12345). If this is a 3-year renewal of an expiring protocol, be sure to report the number
of animals present on campus that need to be transferred.
NOTE: Approval of this IACUC submission authorizes but does not initiate transfer of animals
from one protocol to another or from an expiring protocol to a renewal protocol. A Protocol Transfer
Request form must be completed and submitted for transfer of animals housed in RAR:
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Number Produced In-House - List the total number of animals produced as a result of breeding
animals in this study. The total number is the sum of those used and not-used (excess, wrong genotype,
etc.) in the study
4
Number of Other - List the number of animals and their source (donated, client-owned, etc.)
Notes on breeding & transferring:
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The IACUC Office
University of Minnesota
Rev 12/12
a) If you will be transferring animals from a different IACUC protocol (including breeding protocols)
to this experimental protocol, include those animals, and the relevant ACUP Number (ex. 0802A12345)
in the “Transferred” column, not in the “Produced In-House” column.
Original Signature of PI
Title of PI
Postal Mail to:
IACUC
VCRC 76D
401 East River Parkway
Minneapolis, MN 55455
Date
Campus Mail:
IACUC
MMC 79
Minneapolis Campus
or Deliver to our Office: VCRC 76D (map)
Please call the IACUC Office at 612-626-2126 if you have any questions about how to complete either form.
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