IOWA STATE UNIVERSITY
Institutional Animal Care and Use Committee
Adverse Event/Unanticipated Problem Form
Adverse Event: Any happening not consistent with routine expected outcomes that results in any
unexpected animal welfare issues (death, disease, or distress) or human health risks (zoonotic
diseases or injuries). If you are having a significant number of deaths, and even though it does
not relate to “noncompliance,” it should be reported to the IACUC. An example would be a
significant loss of life due to a disease outbreak, a natural disaster, or an equipment failure.
All material must be typed and submitted immediately by email to iacuc@iastate.edu, then a
signed copy sent to the IACUC Administrator, 1138 Pearson Hall Ames, IA 50011.
Principal Investigator:
Email:
Department:
Telephone:
Project Title:
IACUC Log #:
1. Event/Problem Date:
2. Location of Event/Problem:
3. Severity of Event/Problem:
Moderate
Severe
Fatal
4. Is this event/problem related to the research?
Related
Possibly Related
Not Related
5. Description of the event/problem (include cause, outcome):
6. Description of how the event/problem was managed:
7. Provide a description of the corrective and preventative actions taken to ensure this type
of event/problem does not occur in the future:
8. Does this event/problem necessitate a change in the protocol?
Yes
No
If yes, please complete and submit to the IACUC administrator the “Continuing Review
and/or Modification Form” located on the Forms page of the IACUC website.
__________________________________
Signature of Principal Investigator
_____________________
Date
______________________________________________________________________________
Office for Responsible Research
Updated 01/03/11
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ORR USE ONLY (check all that apply):
Consultation with IACUC Chair Int:
Date:
Copy sent to IACUC for their information;
filed with protocol—no further action required Int:
Date:
Forward to IACUC for review and action Int:
Date:
Write to PI with concerns/schedule PAM visit Int:
Date:
AE/UP Closed
___________________________________
Signature
______________
Date
______________________________________________________________________________
Office for Responsible Research
Updated 01/03/11
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