UPS IACUC Protocol No.
(Office Use Only)
ANIMAL USE PROTOCOL
University of Puget Sound
Institutional Animal Care and Use Committee
(Cover Sheet)
This protocol is required for use of live vertebrate animals as specified in the NIH Guide for the Care and
Use of Laboratory Animals (http://www.nap.edu/catalog.php?record_id=12910#toc).
Protocol Description (Please check one box on each line):
New Project
Renewal
Course Use
Research Use
Laboratory Study
Field Study
Modification
Both
Project Title:
Date of Submission:
(Allow at least 2 weeks for protocol review.)
Principal Investigator/Faculty Sponsor: Typed Name: _______________________
Signature: ________________________
Department/School: _______________________
Telephone Number: __________________________
Emergency contact number: ____________
Co-Investigator/Student:
Typed Name:______________________________________
Signature:_________________________________________
Faculty Advisor’s Statement (student projects only): I,
am the advisor for
. My signature below indicates that I have read the attached protocol and
have checked the contents with the Guidelines.
Signature:
Funding Source:
Effective Period of Investigation:
Has this proposal been or will it be submitted to other Review Boards, departmental committees, or
community agencies for review and approval?
Yes (attach approval letters)
No
PLEASE CHECK ONE OF THE FOLLOWING:
Study involves no significant pain or distress to animals greater than that from routine injection or
x venipuncture.
Study involves the use of appropriate anesthesia, analgesic, or tranquilizer to avoid significant
x pain or distress.
Study involves significant pain or distress without administration of appropriate anesthetic,
analgesic, or tranquilizer.
Office Use Only:
IACUC ACTION: APPROVE
DISAPPROVE
SIGNATURE OF IACUC AGENT(S):
DATE:
Protocol Form Revised 01-22-16
IACUC Protocol Page 2
Part I: NARRATIVE DESCRIPTION OF THE PROJECT
Provide a brief overview of the research, testing, or teaching project. State the overall objectives and the
relevance to human or animal health, advancement of knowledge, and/or the good of society. State the
anticipated risks and benefits of this study. This section must be written in language understandable to
the lay public.
Part II: PROTOCOL STATEMENT
NOTE: Your proposal is being approved for the procedures and techniques described in this protocol
statement. Any changes in protocol (i.e., increase in animal number, increase in pain and/or
distress, etc.) must be approved by IACUC before they are implemented.
A. List the species, number and source of animals to be used. Include animals needed for personnel
training. Give both scientific and common names.
Animal
Number
Source
1.
2.
3.
4.
B. Justification for the use of animals rather than alternatives in your study.
 Provide the rationale for involving live vertebrate animals in this project.
 Explain why each species was chosen for the proposed project.
C. Justification for the number of animals used in your study.
 Describe the basis upon which the total number of animals was determined and how the
number is appropriate for the goals of the project (i.e., minimum number of animals required
to provide sufficient tissue for enzyme preparation; minimum number required to give
statistically valid results, etc.).
 Name the statistical tests used to determine the number of animals employed, and the power
analysis considering the expected variance, mean difference and degree of reliability.
D. Animal Housing
(1)
Laboratory Study
(2)
(a)
Where will the animals be housed?
(b)
Will they be individually_______ or group________ housed?
(c)
Describe the caging used for housing, etc.
(d)
Describe any special requirements for housing (i.e., diet, handling above routine
care). Attach additional pages if necessary.
(e)
Where will the experiments be conducted? List all rooms where animal
experimentation will be conducted and describe what will be done in each room.
Attach additional pages if necessary.
Field Study: Where will the observations be made? Attach additional pages if necessary.
IACUC Protocol Page 3
E. Present evidence that this work does not duplicate work already done in this field. Please list all
applicable databases searched to determine that the proposed experiments are not unnecessarily
duplicative. THE IACUC REQUIRES THAT AT LEAST TWO DATABASES BE SEARCHED. If the project does involve
duplication, please justify the duplication.
F. Will this study cause significant pain or distress to animals?
Yes *_______
No ______ (If no, proceed to Section G.)
*If yes, will anesthetic, analgesic, or tranquilizing drugs used on animals to relieve pain and distress?
Yes _______
(1)
No ______
If yes:
(A) List the drugs and dosages used.
(B) How did you evaluate the appropriateness of these drugs and dosages
(i.e., current literature, consultation with veterinarian, etc.)?
(2)
If no, what is the justification for not using drugs to relieve pain and
distress?
G. Surgical Procedures
(1)
Will this study involve surgical procedures?
Yes ________
No ________ (If no, proceed to Section H.)
If yes, complete parts (2) and (3):
(2)
Will surgery be performed under aseptic conditions?
Yes ________
No ________
If yes, briefly describe the methods used for establishing and maintaining aseptic
conditions.
If no, explain why aseptic conditions will not be used.
(3)
Will animals be allowed to recover from anesthesia?
Note: If the animal is allowed to wake up at all, this is considered to be recovery.
Yes ________
(a)
No ________
If yes, will appropriate measures be taken to alleviate post-operative
pain and distress?
Yes ________ Describe the procedures, including use of any drugs.
No _________ Justify not taking measures to alleviate post-operative pain and
distress.
H. If this project involves field work, describe and justify any procedures for trapping, marking or any
other manipulations of the animals which will be used in the study. Attach additional pages if
necessary.
IACUC Protocol Page 4
I.
What will be the final disposition of the animals at the end of the study?
Euthanized ________ Returned to animal holding ________
If euthanized, describe the method of euthanasia and the justification for use of this method.
If returned to animal holding, note the duration of the residence in animal holding.
Note: If alternative disposition of the animals is planned, attach approval documentation from the
appropriate agencies.
J. Present evidence of experience and/or training of personnel conducting the procedures on the
proposed animal model. Include both investigators and students.
K. Identify any risks or concerns for investigator safety that may result from the proposed animal use
and discuss measures that will be taken to minimize risk to the investigator (and/or students).
LITERATURE CITED