UWSP ANIMAL CARE AND USE PROTOCOL : RENEWAL REQUEST
Please submit the following:

Mail one printed copy with signatures to Sharon Courtney, Grant
Support Office, Old Main, 715-346-3799
IACUC use only
Protocol # ______________
Administrative summary information
Review Date ____________
P.I. name(s)
Action _________________
Project title
First renewal __________
Date (today)
Second renewal __________
Next full review __________
Project dates
Animal study summary information
species (n)
source?
please list each species and include the number of individuals for each in parentheses
indicate if the source of the animals will be ordered from off campus, from a captive colony, or wild
population
lab or field?
indicate if the study of animals will occur in classrooms, labs, animal care facility or other UWSP
housing location, or if the use of animals will occur in the field (free-living conditions)
research or
teaching?
indicate if the animals will be used for research or for teaching (add course name and number of
students)
grant
support?
if work is supported by a research or teaching grant, please list funding agency
surgery?
indicate if (and what type of) surgery will be performed
endpoint
note final disposition of animals (e.g. captive colony, adoption, euthanasia & museum donation)
special
briefly note any special circumstances to bring to the attention of the IACUC
I certify that I will follow the provisions for the care, use and treatment of animals as outlined in the NIH “Guide for
the Care and Use of Laboratory Animals”, or the “Guide for the Care and Use of Agricultural Animals in Agricultural
Research and Teaching”. I assure that these procedures do not unnecessarily duplicate previous experiments.
Principal Investigator (1) _______________________________
_______________________________
sign
Co-Investigator (2) _______________________________
_______________________________
sign
print
print
Department / Division Chair: I am aware of this protocol.
282236370
________________________________
sign
1
Please provide the Committee with a brief status report on the use of animals under this protocol in
the past year, including any unexpected outcomes. Note and explain any change in the number of
requested animals per year.
282236370
2