Rollins College Institutional Animal Care And Use Committee
Protocol Proposal Form – Alternative Form
Instructions.
This is the Alternative Form for protocol submission. The preferred form is a fillable PDF form found
online at http://r-net.rollins.edu/iacuc/files/iacuc-rc-proposal.pdf. Please use the preferred form if
possible. Some of our users have had difficulty saving and or printing the PDF form. If you cannot make
the preferred form work, you may use and submit this alternative form instead. Please type the
answers to all questions. Use as much space in between questions as you require. Please provide
sufficient detail and background and keep in mind that the committee is diverse and unlikely to have
specific expertise in your research area.
Project Title:
Proposal Type (choose: New, Revision, Renewal, Transfer)
[Select Transfer if proposal is being transferred between Principal Investigators; select Renewal if protocol was approved 3
years previously; select Revision if proposal was previously rejected by IACUC.]
Project Personnel
[Principal investigator must be a full‐time or visiting faculty member at Rollins College, must have an advanced degree (PhD or
equivalent) and must have training and experience relevant to the proposed animal‐based research or classroom
demonstration.
Include Name, Office, Phone Number, and Email Address of Principal Investigator and include Name and one form of
contact information for all known Personnel with Supervisory Authority.
Funding Source
[Report internal and external sources of funding, including pending proposals.]
Animal Number and Type
[Below, describe the animals that will be used. You must include all of the following information: 1. The number of animals, 2.
The species, strain (if appropriate), and sex of the animals, 3. The ages of animals, and 4. The source (e.g., commercial vendor)
of animals. IACUC will be unable to review the proposal if any of this information is missing.]
Justification of Animal Use
[IACUC must evaluate whether the use of a particular species of animal is justified, and also must ensure that the minimum
number of animals is being used to accomplish the aims of the proposal. Provide a rationale for both the species used and the
number of animals requested.]
USDA Pain Category
[USDA Pain Category examples are provided at: http://r-net.rollins.edu/iacuc/files/iacuc-rc-paincategories.pdf. Briefly, B –
Breeding only, C – No or minimal distress, D – Alleviated pain, E – Unalleviated pain. Please select the highest category that
applies to the project. You may answer just with a letter, or you may provide additional context.]
Husbandry
[Specify where animals will be housed and, if there are any special nonstandard husbandry arrangements for food, fluid,
lighting, etc., describe them below. Describe anticipated negative effects and how those effects will be monitored and
mitigated.]
Invasive Procedures
[Below, describe any invasive procedures, including drug injections, surgical procedures, exposure to hazardous chemicals or
radiation, blood drawing, etc. For drugs, describe dose, route and frequency of administration, anticipated effects, known side
effects. For surgical procedures, describe preoperative procedures, including type of monitoring of anesthesia, and
postoperative care, including analgesic treatment, and indicate the facility where surgery will be performed.]
Euthanasia / Disposal of Animals
[Indicate whether procedures require animal termination and, if so, how animals will be euthanized.]
Scientific / Educational Aims
[In brief, and in lay language, provide an overview of the aims of the proposal including, if appropriate, history of related
research and scientific hypotheses.]
Procedure
[Provide a detailed description of manipulations, including type, length, and frequency of experimental tests. Particularly when
manipulation may cause distress or pain, indicate rationale and protocol for monitoring and minimizing distress or pain.]
Assurance Statement
[Sign and date (electronically is fine) to indicate your agreement with the following statement.]
The information provided herein is accurate to the best of my knowledge. Procedures involving
animals will be performed only by trained or experienced personnel or under the direct supervision
of trained or experienced persons. Any change in the care and use of animals involved in this
protocol that would affect the welfare of animals will be promptly forwarded to the IACUC for
review. Such changes will not be implemented until the committee’s approval is obtained. The use
of alternative models as replacements for animals in this protocol has been considered and found
to be unacceptable.
Action Taken and Final Signatures
[To be completed by the IACUC Chair.]