Access Form

Supplemental Questionnaire for Research Involving
Human Pluripotent Stem Cells – IACUC
eIACUC Number:
Principal Investigator:
Study Title:
Funding Source:
Instructions to PI: Please complete the questions below, referencing other documents included in your
submission when applicable.
1. Confirm that one of the following is true:
The proposed project will not use any federal funding, including federally funded resources
and facilities.
The proposed project will use federal funding, but is limited to research on pre-existing stem
cell lines that are listed on the NIH stem cell registry.
2. Identify and provide a brief description of any pre-existing human stem cell lines to be used in
this study, including the origin of the cell line and whether it is listed on the NIH registry.
3. Does the research involve the introduction of hESCs or human iPSCs into nonhuman embryos,
fetuses, or adult vertebrate animals?
If Yes, please describe below any potential human contribution to the resulting chimeras,
specifically addressing each of the following:
a. The extent, if any, to which the implanted cells colonize and integrate into the
animal tissue.
b. The degree of differentiation of the implanted cells.
c. Any possibility of contributing to the germ line of the animal.
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d. Any possible effects of the implanted cells on the function of the animal tissue,
particularly the brain.
e. If applicable, procedures for ensuring that the cells do not contribute to the germ
line and/or monitoring the degree to which they may contribute to brain tissue.
Will any resulting chimeras be allowed to breed?
4. Does the research involve the introduction of hESCs or iPSCs into nonhuman mammalian
If Yes, please describe why there is no other alternative experiment that can provide the
information needed.
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