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Western Illinois University Animal Use Protocol Review Form
COVER SHEET
NOTE: If this is a student project, the faculty member supervising the student's work
should complete PI/Course Director (item #1, page 3). The student should complete
"Other Person Responsible for Animals" (item #2, page 3). Both the supervising faculty
member and the student should sign the assurance (page 5).
Project/Course Title:
Principal investigator/course director/department:
List the species and number of animals used.:
This proposal is (check one):
New ___
Continuation ___
Supplement ___
Revision ___
Renewal ___
If this proposed use of animals has been previously reviewed and approved, give the
reference number _______________ and date reviewed _______________________.
On following pages complete items A through G and items 1 through 14.
If more space is needed, please feel free to use back of paper.
DO NOT WRITE IN THIS SPACE
For IACUC Use Only
Reference Number ____________
Date _________________________
Committee Review resulted in:
Approval____
Disapproval ____
Request for full Committee Review____
NOTES:
Signed ________________________________
(IACUC Chair)
Date____________________________
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Western Illinois University Animal Use Protocol Review Form
Summary Of Project
(required)
Please supply answers for all questions. Remember, some of the members of the Institutional
Animal Care and Use Committee may not be familiar with your field of study or the procedures
you propose.
A.
What are the scientific objectives (aims) of your research/classroom activities?
B.
What is the potential value of the study/classroom activities with respect to human
or animal health, the advancement of knowledge, or the good of society? Identify
any information gaps the project/activity is to fill. If there is any duplication of
previous procedures, explain why this duplication is necessary.
C.
Why is the proposed species of animal appropriate to the study/class activities?
forms/_animal . . . 28 January 2002
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Western Illinois University Animal Use Protocol Review Form
D.
Please provide justification for the number of animals you are proposing to use.
E.
Please provide a brief description of the experimental design.
F.
Explain your familiarity, and that of any others directly involved, with the species
care and the procedures to be performed.
G.
Please justify the need to use live animals in the proposed procedures.
forms/_animal . . . 28 January 2002
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Western Illinois University Animal Use Protocol Review Form
1.
Principal investigator/course director:
Office address: _______________________
2.
Other person(s) responsible for animals:
Phone: __________________
Name: _________________________
Office address: _______________________
Phone: __________________
3.
Is this a student project (check one)?
Yes ____
4.
Project/course title:
5.
Source of funding:
6.
Dates of animal use:
From _________________
7.
ANIMALS:
species:
source:
strain:
number:
a
8.
ANIMAL HUSBANDRY:
a) Where will animals be housed? _______________________________________
b) Will animals be housed in other areas for more than 24 hours? Yes __ No __
c) Feeding will be
Standard _____
Non-standard _____
d) Watering will be Standard _____
Non-standard _____
e) Housing will be
Standard _____
Non-standard _____
9.
Explain any non-standard husbandry requirements:
10.
Classify proposed animal use as follows, using all applicable categories:
b
No ____
To ___________________
c________
Type A ___: Pain or distress will not be induced; animals are to be used only for
procedures causing minimum pain or distress, if any.
Type B ___: Procedures would cause pain or distress, however, anesthetics
and/or analgesics will be used to relieve pain or distress (explain below).
Type C ___: Pain or distress will be induced without relief by drug intervention
because such intervention would interfere with the interpretation of project
results (explain below).
forms/_animal . . . 28 January 2002
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Western Illinois University Animal Use Protocol Review Form
11.
Will surgical procedures be involved?
Yes ____
If you answer yes, then answer a through g below:
No ____
a. What surgical facility will be used?
b. Is the procedure intended to be:
Survival _____ Terminal _____
c. Will aseptic technique be used?
Yes ____
No ____
d. Describe the surgical procedure(s):
e. Describe anesthesia protocol:
drug:
dose:
route:
Describe anesthesia monitoring procedures:
f.
Describe postoperative care (include the use of drugs, if any, for relief of
postoperative pain and distress):
g. Will individual animals be subjected to more than one surgical procedure?
Yes ____
12.
No ____
If yes, explain:
Will hazardous agents (infectious, radioactive, toxic mutagenic, or carcinogenic) be
used in animals?
Yes ____
No ____
If yes, provide information for each hazardous agent to be used in animals:
A
B
Agent name:
Exposure:
(route/dose & duration)
Animal location:
(during exposure)
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Western Illinois University Animal Use Protocol Review Form
13.
Describe animal euthanasia procedures to be used. If drugs are used, specify the
drug(s), dose, and route of administration. If animals are not to be euthanized,
explain other disposition.
Who will perform animal euthanasia?
14.
Principal investigator assurance:
a. The information provided herein is accurate to the best of my knowledge.
b. Procedures involving animals will be performed only by trained or experienced
persons or under the direct supervision of trained or experienced persons.
c. Any changes in the care and use of animals involved in this protocol that would
affect the welfare of the animals will be promptly forwarded to the committee
for review. SUCH CHANGES WILL NOT BE IMPLEMENTED UNTIL THE
COMMITTEE'S APPROVAL IS OBTAINED.
d. The use of alternative biomodels as replacements for animals in this protocol
has been considered and found to be unacceptable.
e. These activities do not unnecessarily duplicate previous experiments.
Signature of the principal investigator/course director (if this is a student project both the
supervising faculty member and the student must sign this assurance):
______________________________________
date: ____________________
______________________________________
date: ____________________
forms/_animal . . . 28 January 2002
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