Application for an Amendment to an Individual
Authorisation under Scientific Animal Protection
Legislation
For details on completing this application form, please see the ‘Guide to Applications for
Individuals under Scientific Animal Protection Legislation’.
SECTION A: APPLICANT AND PROPOSED AMENDMENT
INDIVIDUAL AUTHORISATION HOLDER (APPLICANT) DETAILS
Title:
First name:
Surname:
Breeder/supplier/user
name:
Address 1:
Address 2:
Address 3:
County
Telephone:
E-mail:
Student/Staff Number;
Current position:
Individual authorisation number:
AE
/I
Is the specific individual authorisation subject to a specific condition?
Yes
No
If yes, provide evidence that the specific condition has been not been fulfilled. Please
comment:
PROPOSED AMENDMENT
Tick all that apply and enter details in relevant parts in Section B below.
Part 1: Project managing: Addition of this new purpose or addition of a new species for
this purpose
Part 2: Carrying out procedures: Addition of this new purpose or addition of a new
category of procedure and/or new species for this purpose
Part 3: Performing euthanasia: Addition of this new purpose, or addition of a new method
of euthanasia and/or new species for this purpose, or addition of an unauthorised location
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SECTION B: PROPOSED AMENDMENT DETAILS
Please use section B part(s) 1, 2, 3 and/or 4 to complete the necessary details for the amendment
type(s) selected above.
PART 1: PROJECT MANAGING
Indicate the species of animal(s) for which authorisation is sought:
Species
PART 2: CARRYING OUT PROCEDURES ON ANIMALS
Select the category of procedure and the species of animal(s) for which authorisation is sought
using the tables below. Select all that apply.
USE OF NEUROMUSCULAR BLOCKING AGENTS
Note: evidence of education, training and experience must be provided through submission
of CV and training records.
Species
NON-INVASIVE BEHAVIOURAL PROCEDURES HAVING THE POTENTIAL TO CAUSE
THE ANIMAL PAIN, SUFFERING, DISTRESS OR LASTING HARM
Species
BREEDING OF GENETICALLY MODIFIED ANIMALS
Species
SURGICAL PROCEDURES INVOLVING GENERAL ANAESTHESIA AND ANALGESIA
Species
NON-RECOVERY PROCEDURES (INCLUDING SURGICAL PROCEDURES) CONDUCTED
UNDER TERMINAL GENERAL ANAESTHESIA
Species
MINOR/MINIMALLY INVASIVE PROCEDURES INVOLVING SEDATION, ANALGESIA
OR GENERAL ANAESTHESIA
Species
MINOR/MINIMALLY INVASIVE PROCEDURES NOT REQUIRING SEDATION,
ANALGESIA OR GENERAL ANAESTHESIA
Species
NUTRITIONAL MODIFICATIONS RESULTING IN DEFICIENCIES IN ANIMALS DIETARY
NEEDS AND/OR WITHDRAWAL OF FOOD FOR A PERIOD OF 24 HOURS OR MORE
Species
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OTHER PROCEDURES, PLEASE SPECIFY
Species
PART 3: PERFORMING EUTHANASIA
Non-human
primates
Large
Mammals
Rabbits
Rodents
Birds
Reptiles
Amphibians
Method
Fish
Animal
Dogs, Cats,
Ferrets, Foxes
Indicate the species of animals for which authorisation is sought in the table below. Select all
that apply.
Anaesthetic overdose
Captive bolt
Carbon dioxide
Cervical dislocation
Concussion/ percussive
blow to the head
Decapitation
Electrical stunning
Inert gases (Ar, N2)
Shooting with a free bullet
with appropriate rifles,
guns and ammunition
If a method of euthanasia other than the methods approved in Annex IV of Directive
2010/63/EU is to be used, provide details on the method proposed and a justification as to why
this method is necessary:
Other than the authorised user establishment, list any additional unauthorised location where
you plan to conduct euthanasia (outside of a project authorisation) if relevant:
Provide a scientific justification as to why this additional unauthorised location is necessary:
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SECTION C: DECLARATION AND UNDERTAKING
DECLARATION AND UNDERTAKING
The declaration and undertaking must be signed by the individual applicant and the compliance
officer responsible for ensuring compliance with the provisions of Directive 2010/63/EU and S.I. No.
543 of 2012 at the registered breeder/supplier/user.
Applicant
I hereby declare that an amendment to the authorisation identified in section A above is sought
for the purposes indicated above in Sections A and B and that the information provided in this
application form is correct and complete.
I hereby declare that, in the event of the authorisation being granted:
- I will respect the principles of replacement, reduction and refinement (i.e. the 3R principles)
and comply with the terms and conditions of the authorisation.
- I will use the authorisation only for the purposes stated above in Sections A and B.
I hereby undertake, in the event of the authorisation being granted, to ensure fulfilment of the
obligations arising by virtue of the terms and conditions of the authorisation.
Signature of applicant: ______________________
Print/type name:
Date:
Compliance officer responsible for ensuring compliance with the provisions of Directive
2010/63/EU and S.I. No. 543 of 2012 at the registered/authorised establishment
I hereby declare that
- the applicant is affiliated to the primary breeder/supplier/user referred to in Section A.
- I understand that if the applicant fails to uphold his/her responsibilities under Directive
2010/63/EU and S.I. No. 543 of 2012, this may have implications for the continued
authorisation of the breeder/establishment/user concerned.
I hereby undertake, in the event of the amendment authorisation being granted to the applicant:
- That he/she has or shall be provided with appropriate training, education and experience for
the work outlined in this application.
- That if he/she is a first time applicant, that he/she shall be supervised in the performance of
the above tasks until he/she has demonstrated requisite competence.
- To ensure maintenance of accurate and, up-to-date training records demonstrating training
received by, supervision provided to, and competence attained by, the applicant.
Signature of compliance officer: ______________________
(on behalf of breeder/supplier/user)
Print/type name:
Date:
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CHECKLIST
CV (mandatory for the use of neuromuscular blocking agents only)
Training record (mandatory for the use of neuromuscular blocking agents only)
Evidence of having fulfilled specific conditions (where relevant)
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