CHARLES STURT UNIVERSITY
ANIMAL CARE AND ETHICS COMMITTEE
ANIMAL RESEARCH APPLICATION FORM
To expedite resolution of any minor issues raised by the ACEC during consideration of your application, please
provide a landline telephone contact number appropriate for the duration of the relevant ACEC meeting.
Alternatively you are welcome to speak to your application at the meeting. If you wish to address the meeting,
please contact the ACEC’s Executive Officer on 6338 4773.
Telephone Number:
OFFICE USE ONLY
Date Received:
/
/
Period of Approval:
/
/
to
/
ACEC Agenda Item No.:
__________________
Protocol No.:
__________________
/
Executive Officer, ACEC _____________________________________
Date:
__________________
NOTE: This form must be typed.
SECTION 1: ADMINISTRATION
1.
TITLE OF PROJECT:
2.
WHAT SPECIES OF ANIMAL WILL BE USED?
SPECIES
3.
Scientific Name
Breed / Strain
Age
Sex
Weight
PRINCIPAL INVESTIGATOR:
Where this investigation is part of a student’s research project, their Principal Supervisor must be nominated on this form as the
Principal Investigator. Other participants (including students) must be listed in the appropriate section of the form.
Name and Designation:
School / Section:
School / Section Address:
CONTACT DETAILS:
Telephone
Between hours
After hours
Email Address
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4.
DATES FOR APPROVAL (Use DD/MM/YY format)
From:
To:
For ongoing work where methodology does not change, you may apply for an approval period of up to
three (3) years after the proposed commencement date, as the ACEC can approve ongoing projects for
up to 3 years subject to receipt of annual reports (ACEC R2). Please note that Annual Review
Forms are required under the Australian Code for the Care and Use of Animals for Scientific
Purposes (2.4.34)
5.
DESCRIPTION OF RELATIONSHIP OF PRINCIPAL INVESTIGATOR WITH THE INSTITUTION:
(Employee, Collaborative Research, Independent of CSU, etc.)
6.
A. HAS AN EXTERNAL ORGANISATION AGREED TO SUPPORT THIS APPLICATION, OR HAS AN
APPLICATION FOR EXTERNAL SUPPORT BEEN LODGED?
Choose one:
Yes 
No

If YES, provide details (i.e., name of the organisation and date of application, and whether the application
has, to date, been successful.)
B. IF A FUNDING APPLICATION IS NOT SUCCESSFUL, WILL THE PROJECT STILL PROCEED?
Choose one:
Yes 
No

7.
A.
IS THIS APPLICATION FOR A NEW PROJECT?
Choose one:
Yes 
No


B. IS THIS APPLICATION FOR A PROJECT WHICH BEEN, PREVIOUSLY OR SIMULTANEOUSLY,
SUBMITTED TO THIS OR ANOTHER ETHICS COMMITTEE?
Choose one:
Yes 
No

If YES, provide reasons for resubmission or simultaneous submission, and the name of the AEC or AECs
and approval numbers where appropriate.
C. IS THIS APPLICATION FOR A SIGNIFICANTLY REVISED CURRENT PROTOCOL?
Choose one:
Yes 
No

If YES, quote the approval number, species and number of animals used to date.
8.
ARE YOU USING (Please delete the response that does not apply):
X-Radiation
Yes/No
Gamma Radiation
Yes/No
Laser Radiation
Yes/No
Recombinant DNA Technology
Yes/No
Infectious materials
Yes/No
Toxic materials
Yes/No
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Carcinogenic materials
Yes/No
Other harmful agents
Yes/No
If YES:
A. Will precautions be taken in accordance with statutory requirements and have relevant personnel been
informed?
Choose one:
Yes
No


B. Has the appropriate authority or licence from the applicable University Compliance Committee been
obtained?
(Approval from the University Biosafety Committee or University Radiation Safety Committee, etc.)
Choose one:
9.
Yes 
No

Not Applicable

DOES THE PROJECT INVOLVE NATIVE, SPECIALLY IMPORTED OR PROTECTED SPECIES?
Choose one:
Yes 
No

If YES:
A. Have the relevant licences been obtained from the National Parks and Wildlife Services or other
authorities?
Choose one:
Yes
No


B. Permit Type and Number
10.
HAVE ANY OF THE PEOPLE PARTICIPATING IN THE PROJECT HAD ANY ANIMAL RESEARCH
AUTHORITY OR ANIMAL SUPPLIER’S LICENCE CANCELLED?
Choose one:
Yes 
No

If YES, please provide details including the name of the person, the date on which the authority or licence was
cancelled, who cancelled the authority and the reason for cancellation:
Name of Staff
Member
Date Authority /
Licence Cancelled
Name of Cancelling
Body
Reason for Cancellation
of Authority / Licence
SECTION 2: JUSTIFICATION FOR ANIMAL USE
AIMS OF THE PROJECT IN LAY TERMS
The Code of Practice states that “Animal experiments may only be performed when the scientific merit
justifies the use of animals”.
Your answer is crucial for the assessment of scientific merit and the necessity of animal use. USE LAY
TERMS AND EVERYDAY ENGLISH as much as possible; terms that will be understood by a member of
the Committee without a scientific background.
11.
DESCRIBE THE AIMS OF THE PROJECT IN LAY TERMS A PERSON WITHOUT A SCIENTIFIC
BACKGROUND WILL UNDERSTAND. COMMENT ON THE SIGNIFICANCE OF THE RESEARCH
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WHICH YOU BELIEVE JUSTIFIES THE USE OF ANIMALS. SPECIFY WHAT YOU HOPE TO
ACHIEVE. PLEASE GIVE THE BACKGROUND TO THIS PROJECT, WITH A SUPPORTING LIST OF
KEY REFERENCES.
12.
IF THE PROJECT REPEATS PREVIOUSLY-REPORTED EXPERIMENTS, GIVE THE REASONS FOR
THE EXPERIMENTS BEING REPEATED.
REASONS FOR ANIMAL USE
13.
A. WHY IS IT NECESSARY TO USE ANIMALS IN THIS EXPERIMENT?
B. WHAT ALTERNATIVES TO ANIMAL USE HAVE BEEN CONSIDERED AND WHY IS IT NOT
POSSIBLE TO USE THESE?
14.
WHY HAS THIS SPECIES OF ANIMAL (AND, IF APPLICABLE, AGE, SEX AND WEIGHT) BEEN
CHOSEN?
15.
A. HOW MANY ANIMALS WILL BE REQUIRED?
B. EXPLAIN, ON THE BASIS OF EXPERIMENTAL DESIGN, WHY THIS NUMBER OF ANIMALS
WILL BE REQUIRED
Wherever possible, a power analysis with alpha value should be included or, if this is not possible, a
comprehensive explanation.
SECTION 3: ETHICAL CONSIDERATIONS
AN ASSESSMENT OF THE IMPACT ON ANIMAL WELL-BEING
SEQUENCE OF EVENTS
16.
GIVE DETAILS (SEQUENTIALLY) ON WHAT HAPPENS TO THE ANIMAL(S) FROM THE TIME YOU
OBTAIN THEM UNTIL USE OF THE ANIMAL(S) IS COMPLETE.
A flow chart or Sequence of Events table may assist in making this information clear.
Please list any Standard Operating Procedures which are to be used – please refer to the ACEC Register of
Standard Operating Procedures on the ACEC website for a complete list of Standard Operating Procedures
(SOPs) already approved by the Animal Care and Ethics Committee. If you are submitting a new Standard
Operating Procedure for approval by the Committee, please insert “None- New for Approval” under “SOP
Number”.
SOP Number
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SOP Name
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If any media-related activities arise from this research (for example, photo shoots for newspaper / magazine /
journal features or filming for documentaries or television news features), you will need to advise the Animal
Care and Ethics Committee and submit photographs or filming to the Committee as part of the animal use
associated with this project.
IMPACT
18.
A. IDENTIFY ALL FACTORS AND PROCEDURES THAT MAY HAVE AN IMPACT ON AN
ANIMAL’S WELL-BEING, AND PROVIDE DETAILS OF HOW YOU WILL MONITOR THE
IMPACT.
Factors may include handling, housing, etc., as well as specific experimental procedures. Refer to the CHECKLIST at the end
of this application form to ensure all details have been considered and refer to published standard operating procedures where
appropriate.
B. DESCRIBE EACH FACTOR OR PROCEDURE AND DETAIL HOW ANY ADVERSE IMPACT WILL
BE MINIMISED.
Details should include treatment substances, dose rates, routes of administration, anaesthetic and analgesic regimes, etc., as
applicable. Refer to the CHECKLIST to ensure that all details have been considered.
ANIMAL MONITORING
19.
WHO WILL MONITOR THE ANIMALS A. During weekdays?
Please tell the Committee what experience the person has relevant to care of the species to be used in the
project, and how many years’ experience with those animals that nominee has.
NAME
QUALIFICATIONS
EXPERIENCE WITH SPECIES USED
B. At night (If applicable)?
Please tell the Committee what experience the person has relevant to care of the species to be used in the
project, and how many years’ experience with those animals that nominee has.
NAME
QUALIFICATIONS
EXPERIENCE WITH SPECIES USED
C. During weekends and holidays?
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Please tell the Committee what experience the person has relevant to care of the species to be used in the
project, and how many years’ experience with those animals that nominee has.
NAME
20.
QUALIFICATIONS
EXPERIENCE WITH SPECIES USED
DESCRIBE HOW THE ANIMALS WILL BE MONITORED
A. While the procedures are being carried out.
Include frequency and methods used.
B. For the duration of the project.
Include frequency and methods used.
ANIMAL HOUSING AND MANAGEMENT
21.
PROVIDE FULL DETAILS OF A. Where animals will be housed:
B. The maximum and minimum number of animals per cage / pen:
C. The type of housing to be provided:
D. Where procedures will be performed:
E. What animals will be fed, and how often will they be fed?
F. Who will be responsible for the management of emergencies, and how you will ensure that the nominee(s)
can be contacted (Refer also to Question 28):
G. Outline the contingency measures you have in place for the management of injured animals, or animals
extraneous to the project.
H. Have you consulted with the relevant animal house Manager on the detail of how the animals are to be
housed, fed, watered and have environmental enrichment, etc., provided for them during this project?
Choose one:
Yes
No


DECLARATION BY MANAGER, ANIMAL HOUSE / MANAGER, HOLDING FACILITY:
Please cross out the sections below that do not apply
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I confirm that housing is available in the Animal House / Holding Facility for the number of animals requested
for the research period nominated, and that the Animal House / Facility staff can provide adequate
maintenance and care of the animals during that time
OR
Housing will be available for _______ animals in the Animal House / Holding Facility for the research period
nominated. Additional housing will be provided at:
_________________________________________________________________________________
There will be staff at both facilities to provide adequate maintenance and care of the animals during that
time.
OR
Housing and staff to provide adequate maintenance and care of the animals are not available in the Animal
House / Holding Facility for the animals requested during the research period nominated.
Name:
_______________________________________________________
Signed:
_______________________________________________________
Animal House / Facility name:
Date:
____________________________________________________________
_______________________________________________________
DECLARATION BY PRINCIPAL INVESTIGATOR:
I have personally inspected the animal housing / holding facility to be used during this research project, and I
am satisfied in regard to the smooth running of the housing facility for the duration of the project.
Signature:
_______________________________________________________
SOURCE
22.
FROM WHERE WILL THE ANIMALS BE OBTAINED?
DURATION
23.
WHAT WILL BE THE MAXIMUM TIME THAT AN INDIVIDUAL ANIMAL WILL BE HELD FOR IN
THIS EXPERIMENT?
RE-USE
24.
DOES THIS PROJECT INVOLVE THE USE OF ANY ANIMALS THAT HAVE BEEN THE SUBJECT OF
PREVIOUS RESEARCH?
Choose one:
Yes 
No

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If YES, what has previously been done to these animals? Include project name(s) and identification
number(s).
FATE OF ANIMALS
25.
WHAT WILL HAPPEN TO THE ANIMALS AT THE COMPLETION OF THE PROJECT?
26.
WILL FACTORS AFFECTING ANIMALS DETERMINE THE ENDPOINT OF THE PROJECT?
(tumour size, maximum weight loss, etc.)
Choose one:
Yes
No
If YES, give details.


If NO, what will be the endpoint?
27.
IF ANIMALS ARE TO BE EUTHANASED
A. How will this be done?
B. Where will euthanasia be carried out?
C. Who will carry out the procedure, and what is their experience in the technique to be employed?
D. Could animal tissue be shared with other Investigators?
TECHNICAL
28.
LIST THE QUALIFICATIONS AND EXPERIENCE OF ALL PERSONNEL WHO WILL BE
PARTICIPATING IN THE ANIMAL COMPONENTS OF THE PROJECT.
Detail whether the experience is with the species being used, as well as whether the experience is with the
procedures being undertaken.
Please tell the Committee what experience the person has relevant to the procedure to be performed, and
how many years’ experience in that field that nominee has.
POSITION
NAME &
QUALIFICATIONS
EXPERIENCE IN
PROCEDURES TO BE
UNDERTAKEN AND THE
SPECIES BEING USED.
CONTACT DETAILS:
- work phone no.
- home phone no.
- email address
If no experience,
describe how relevant
experience will be
obtained
Principal Investigator
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Associate Investigator(s)
Student
Student’s Supervisor
(if not listed above)
Other participants
Nominee for emergencies
1.
2.
SECTION 4: DECLARATION OF RESPONSIBILITIES
A.
DECLARATION BY THE PRINCIPAL INVESTIGATOR
I certify that the use of animals in this project will conform with the NSW legislation and the general principles of the
NHMRC / CSIRO / AAC Australian Code of Practice for the Care and Use of Animals for Scientific Purposes. I accept
responsibility for the conduct of all procedures detailed in this application and for the supervision of all personnel
delegated to perform any such procedures.
I confirm that all personnel have read this application and have agreed to comply with procedures described and any
conditions imposed by the ACEC.
I confirm that I have taken into account potential hazards to staff working with animals in this project, and have ensured
that appropriate safety measures have been implemented.
Principal Investigator:_________________________________________
(Signature)
Date: ______________________
(Print Name)
B.
DECLARATION BY HEAD OF SCHOOL / SECTION (AS APPLICABLE)
I have read this application and am satisfied that the use of animals is justified on scientific, educational or diagnostic
grounds.
Head of School / Section:_______________________________________
(Signature)
ACEC R1
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Date:_____________________
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(Print Name)
School / Section:_________________________________________
SUBMIT THIS FORM TO: The Executive Officer, Animal Care and Ethics Committee
Office of Governance and Corporate Affairs
Charles Sturt University – Bathurst campus
Building 1294-L3
Email: animalethics@csu.edu.au
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LAST UPDATED 04.01.16
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CHECKLIST



Anaesthesia
 Fasting
 Induction – drug, dose, route
 Maintenance – drug, dose, route
 Methods of monitoring
What is happening to the animals?
What will be the effects?
How will the effects be minimised?
Euthanasia
 Method
 Location (where procedure will
be performed)
 Expertise of personnel
anaesthesia and recovery
 Additional support during
anaesthesia and recovery (e.g.,
heat, intravenous fluids)
 Location of induction and
recovery areas
Behaviour Modification
 Stimulus (type, duration,
frequency)
Blood / Body Fluid Collection
 Volume
 Route
 Frequency
 Anaesthesia or analgesia
 Restraint
 Animal monitoring (methods &
frequency)
Diet / Water Modifications
 Type
 Amount
 Effects
 Measurement of Intake
 Animal Monitoring
Drug Treatments








Substance
Volume
Route
Frequency / total number per
animal
Local and systemic effects
Anaesthesia or analgesia
Possible side effects
Restraint
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Genetic Manipulation
 Methods
 Potential effects
Housing
 Location
 Group housing (stocking rates,
sexes)
 Isolation
 Shelter
 Bedding
 Hiding areas
 Environmental enrichment
 Duration held
 Conditioning period
In-vitro Studies
 Source of animals
 Duration held
 Euthanasia
Surgery
 Anaesthesia
 Location of pre-operative
preparation area
 Surgical procedure (site,
technique)
 Sterile technique (instruments,
drapes, surgeon)
 Location of and housing in postoperative recovery area
 Post-operative management
 Post-operative monitoring
(methods, frequency, duration)
 Use of analgesics (type, dose,
route, frequency, means of
determining necessity for use)
 Expertise
Toxicology
 Substance
 Volume
 Route
 Frequency of treatments /
Total number per animal
 Local and systemic effects
 Anaesthesia or analgesia
 Restraint
 Animal monitoring (methods and
frequency
 Endpoint / duration
 Tumour / neoplasia induction
 Method
 Site
 Endpoint
 Animal monitoring (methods,
frequency
Transport
 Type
 Duration
 Confinement
 Numbers of animals
 Air conditioning
Teaching
 Source of animals
 Housing
 Duration held
 Method of disposal
Wildlife Studies
 Location
 Methods
 Capture methods
 Handling methods
 Handling / restraint
 Housing / holding
 Monitoring
 Release
 Effects on population
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