IACUC Number:
B
Boston College
IACUC Breeding Colony Protocol
Instructions: Complete this protocol form when breeding any vertebrate animals for teaching, testing or research at Boston College.
This application is also reviewed for biosafety, and radiation safety, so complete information on potential deleterious effects of
solutions used in the tissue analysis or preparation must be included in this application. Incomplete applications will not be
forwarded to the IACUC for review.
Date of Application:
Title :
A. ADMINISTRATIVE DATA
1. Principal Investigator:
2. School/Department:
3. Mailing Address:
4. Telephone:
5. Email:
7. Research Personnel/staff/students: List all personnel who will handle the animals or animal tissues:
Name:
E-mail:
Date of ACF Training:
Name:
E-mail:
Date of ACF Training:
Name:
E-mail:
Date of ACF Training:
Name:
E-mail::
Date of ACF Training:
Name:
E-mail::
Date of ACF Training:
8. Funding Sources
A.
None -- Do you plan to apply for funding in the future?
Yes
No
B.
University Funded: List source:
C.
External: List source and grant number:
D.
Federal*: List agency, department and grant number:
*submit a complete copy of the Federal funding proposal with your IACUC application and highlight or indicate where funds for
animal breeding are requested. If the proposal is silent on animal breeding, then submit a copy of the award document and identify
where the sponsor has agreed to pay for animal breeding.
Provide Per Diem Expense Chartstring:
B.
ANIMAL REQUIREMENTS
1. Total Number of Animals in All Strains to be Bred
STRAIN A
Number of Animals in this Strain:
1. Genus:
4. Strain, subspecies, or breed:
2. Species:
3. Common name:
5. Common name:
6. Bacteriological status:
[e.g., germfree (axenic), defined flora (gnotobiotic), specific pathogen free, conventional]
7. Viral status:
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8. Will animals be housed in BC
Animal Care Facility?
Yes
No
If No indicate the institution, or BC building and room where animals will be housed:
STRAIN B
Number of Animals in this Strain:
1. Genus:
2. Species:
4. Strain, subspecies, or breed:
3. Common name:
5. Common name:
6. Bacteriological status:
[e.g., germfree (axenic), defined flora (gnotobiotic), specific pathogen free, conventional]
7. Viral status:
8. Will animals be housed in BC
Animal Care Facility?
Yes
No
If No indicate the institution, or BC building and room where animals will be housed:
STRAIN C
Number of Animals in this Strain:
1. Genus:
2. Species:
4. Strain, subspecies, or breed:
3. Common name:
5. Common name:
6. Bacteriological status:
[e.g., germfree (axenic), defined flora (gnotobiotic), specific pathogen free, conventional]
7. Viral status:
8. Will animals be housed in BC
Animal Care Facility?
1. Genus:
Yes
No
If No indicate the institution, or BC building and room where animals will be housed:
STRAIN D
Number of Animals in this Strain:
2. Species:
4. Strain, subspecies, or breed:
3. Common name:
5. Common name:
6. Bacteriological status:
[e.g., germfree (axenic), defined flora (gnotobiotic), specific pathogen free, conventional]
7. Viral status:
8. Will animals be housed in BC
Animal Care Facility?
1. Genus:
4. Strain, subspecies, or breed:
Yes
No
If No indicate the institution, or BC building and room where animals will be housed:
STRAIN E
Number of Animals in this Strain:
2. Species:
3. Common name:
5. Common name:
6. Bacteriological status:
[e.g., germfree (axenic), defined flora (gnotobiotic), specific pathogen free, conventional]
7. Viral status:
8. Will animals be housed in BC
Animal Care Facility?
rev. 06/16/14
Yes
No
If No indicate the institution, or BC building and room where animals will be housed:
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C.
TRANSPORTATION
Transportation of animals must conform to all institutional guidelines/policies and federal regulations. If animals will be
transported on public roads or out of state, describe efforts to comply with USDA regulations. If animals will be transported
between facilities, describe the methods and containment to be utilized. If animals will be transported within a facility, include
the route and elevator(s) to be utilized.
Full description of transportation within the facility:
Description of animal transportation in and out of facility:
D. RATIONALE FOR ANIMAL USE
1. Explain rationale for animal breeding (include reasons why non-animal models cannot be used):
2. Justify the appropriateness of the species selected. (The species selected should be the lowest possible on the phylogenetic
scale):
3. Justify the number of animals to be bred. (The number of animals bred should be related the minimum number required in
research protocols to which animals will be transferred to obtain statistically valid results ]:
4. What is the basis of your number calculation (e.g., power analysis, publication or other factors):
E. HAZARDOUS AGENTS
The use of hazardous agents requires the approval of the Institutional Biosafety Committee and/or the Radiation Safety Committee
Attach documentation of the required approval by one or both of those committees.
Hazardous Agent
Yes
No
Agent
Date of Biosafety or Radiation
Safety Approval
Tracking #
Radionuclides
Biological Agents
Hazardous Chemicals or Drugs
Recombinant DNA
Study Conducted at Animal Biological Safety Level: 1
2
3
4
For information on Animal Biosafety Levels please contact the Office for Research Protections
Describe the practices and procedures required for the safe handling and disposal of contaminated animals and material associated
with this study. Also describe methods for removal of radioactive waste and, if applicable, the monitoring of radioactivity:
Additional safety considerations:
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F. BIOLOGICAL MATERIAL/ANIMAL PRODUCTS FOR USE IN ANIMALS (e.g., cell lines, antiserum, etc.)
1. Specify Material:
2.
Source:
Material Sterile or Attenuated: Yes
If derived from rodents, has the material been PCR Assay tested?
Yes
3.
(Attach copy of results)
No
or No
I certify in signing this form that the PCR Assay tested materials to be used have not been passed through rodent species
outside of the animal facility in question and/or the material is derived from the original PCR Assay tested sample. To the best of
my knowledge the material remains uncontaminated with rodent pathogens.
G. TRANSGENIC AND KNOCKOUT ANIMALS
Describe any phenotypic consequences of the genetic manipulations to the animals. Describe any special care or monitoring that
the animals will require.
H. SPECIAL CONCERNS OR REQUIREMENTS OF THE STUDY
List any special housing, equipment, animal care (e.g., special caging, water, feed, or waste disposal, environmental enhancement,
etc.) or other information you would like the IACUC to consider when reviewing this proposal.
Signature Page Follows
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I. PRINCIPAL INVESTIGATOR CERTIFICATIONS
Please note that certified electronic signature are allowed or scanned, faxed, or handwritten signature are also acceptable to
process the application
1. I certify that I have attended the institutionally required investigator training course.
Year of Course Attendance:
Location:
2. I certify that I have determined that the research proposed herein is not unnecessarily duplicative of previously reported
research.
3. I certify that all individuals working on this proposal who are at risk are participating in the Institution's Occupational Health
and Safety Program.
4. I certify that the individuals listed in Section A. are authorized to conduct procedures involving animals under this proposal,
have attended the institutionally required investigator training course, and received training in: the biology, handling, and care
of this species; aseptic surgical methods and techniques (if necessary); the concept, availability, and use of research or testing
methods that limit the use of animals or minimize distress; the proper use of anesthetics, analgesics, and tranquilizers (if
necessary); and procedures for reporting animal welfare concerns.
5. I certify that I will obtain approval from the IACUC before initiating any significant changes to the research protocols to which
animals bred under this protocols will be transferred.
6. I certify that I will notify the IACUC regarding any unexpected events that impact the animals. Any unanticipated pain or
distress, morbidity or mortality will be reported to the attending veterinarian and the IACUC.
7. I certify that I am familiar with and will comply with all pertinent institutional, state, and federal rules and policies.
Principal Investigator:
Name :
J
Signature:
Date:
. CONCURRENCES
Faculty Supervisor required for student submissions:
Name & Title:
Signature:
Date:
BC Biosafety Committee Certification of Review and Concurrence: (Required of all studies utilizing bio-hazardous agents.)
Name & Title:
Signature:
Date:
BC Radiation Safety Committee Certification of Review and Concurrence: (Required of all studies utilizing radiation agents.)
Name & Title:
rev. 06/16/14
Signature:
Date:
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Instructions: Complete this protocol form when breeding any