Institutional Animal Care and Use Committee (IACUC)
Office of Regulatory & Research Compliance (ORRC)
University at Albany, MSC 309
(Phone) 518-437-3850 (Fax) 518-437-3855 (E-mail) iacuc@albany.edu
Date Received
ORRC Assigned : JG ___ TR ___
AB___
Date: _______________
Submission #
Date of determination: ________________
INSTITUTIONAL ANIMAL CARE AND USE COMMITTEE (IACUC)
MODIFICATION FORM




11.01.13
Depending on type of modification, you may need to submit supplemental form(s) along with this
“Modification form”. Please read “Modification Check List” on page 2 of this form.
Incomplete submissions will not be processed.
Supplemental forms are available on the Regulatory & Research Compliance website at
http://www.albany.edu/orrc/iacuc-forms.php. Under IACUC forms, go to Additional IACUC Forms.
If you have questions regarding this form, please contact the Office of Regulatory & Research Compliance
at 518-437-3850 or IACUC@albany.edu.
**If you have more than 2 modifications/changes or changes are significant, it may be necessary to
submit as “NEW PROTOCOL”. Please contact the Office of Regulatory& Research Compliance BEFORE you submit
the modification form, if you are not sure.
MODIFICATION REQUEST: SECTION 1
1-1. General Information
PI Information
Protocol #
-
Protocol Title
Name of PI
Department
Campus address
E-mail Address
Phone
Fax
PI Level
Faculty
Undergraduate
Status of the activities
proposed in this
protocol
Postdoctoral
Other : (
Graduate student
)
A. Active - project ongoing.
B. Currently inactive - project was initiated but is presently inactive.
C. Inactive - project never initiated but anticipated start date is (
Co-PI Information (if applicable)
Protocol #
-
Protocol Title
Name of PI
Department
Campus address
E-mail Address
Phone
Fax
Co-PI Level
Faculty
Undergraduate
Postdoctoral
Other : (
Graduate student
)
)
1-2.
MODIFICATION CHECK LIST: Check applicable items and complete appropriate forms as
indicated. All Supplemental forms can be found at www.albany.edu/orrc/iacuc-forms.php.
Changes to study personnel should be requested using the IACUC Request to Add or
Delete Key Personnel
REQUESTED CHANGE(S)
DESCRIPTION
Funding source
Change funding information
Experimental Site Change
Rooms or building changes
Animals
Euthanasia
Anesthesia/Analgesia
Drug administration
Changes in number of animals, Species, strain, or
Genotype, Conditions (sex and Age), Source or
method of Animal Acquisition etc
Changes in the euthanasia
Changes in method, type and/or dosage of drag,
Rout of administration, frequency, timing, and
purpose etc
Surgical procedure
Changes in method, type, dosage of drag, purpose,
pre-/post- surgical operations, etc
Behavioral testing
procedure
Changes in method, type, equipment, frequency,
timing of testing, etc
Pain and Distress
Changes or adding in type, timing, frequency of
pain and distress.
Bio-toxic and controlled
substance use
Changes in method, type and/or dosage of drag,
Rout of administration, frequency, timing, and
purpose etc
Blood/Tissue Collection
Changes in method, numbers, type, frequency,
timing, and purpose etc
Breeding colony
Other
Changes in breeding colony; numbers of animals
(breeding pair, offspring, experimental animals etc)
breeding method, etc.
Specify:
REQUIRED FORM/DOCUMENT
*Page 2 of this form: Section2-2
“FUNDING INFORMATION”
*Page 2 of this form Section 2-3
“ROOM INFORMATION”
*Page 3 of this form: Section 3-2
“CHANGES IN ANIMALS”
*Page 2 of this form Section 3-1
“EUTHANASIA” section.
*Page 3 of this form: Section 3-3
“JUSTIFICATION FOR CHANGE(s)”
*Supplemental Form 4 page 1~2:
“Drug administration”
*Page 3 of this form: Section 3-3
“JUSTIFICATION FOR CHANGE(s)”
*Supplemental Form 6:“Surgery”
*Page 3 of this form: Section 3-3
“JUSTIFICATION FOR CHANGE(s)
*Supplemental Form 2:“Behavioral
test”
*Page 3 of this form: Section 3-3
“JUSTIFICATION FOR CHANGE(s)”
*Supplemental Form3 : “Pain and
Distress”
*Page 3 of this form: Section 3-3
“JUSTIFICATION FOR CHANGE(s)”
*Supplemental Form5 : “Biological
Toxin Administration”
*Page 3 of this form: Section 3-3
“JUSTIFICATION FOR CHANGE(s)”
*Supplemental Form 1 :
“Collection or Receipt of Biological
Samples”
*Page 3 of this form: Section 3-3
“JUSTIFICATION FOR CHANGE(s)”
*Supplemental Form8 : “Breeding
Colony ”
*submit separate document that
include modified items, justification.
MODIFICATION REQUEST SECTION 2.
Provide following information for your modification:
2-1.BRIEF DESCRIPTION OF MODIFICATION (IN WORDS UNDERSTANDABLE TO A LAYPERSON)-space is
limited to 500 characters
2-3. FUNDING SOURCE: If any source is new or if there were any changes in previously submitted funding
information, provide a copy of the relevant sections of the grant application along with face page for
review.
Page 2
NEW funding information: (Agency)
(Funding date):
2-4. EXPERIMENTAL SITE CHANGE- NEW ROOM INFORMATION: If you need to change or add room(s) to
your experiment, which includes animal housing rooms, indicate new room numbers and description.
CURRENT ROOM
NEW ROOM
→
DESCRITPTION FOR NEW ROOM USAGE
→
→
→
→
→
* Justification for the changes (If involve multiple room changes, provide justification for EACH change):
MODIFICATION REQUEST SECTION 3
3-1. EUTHANISIA:
*Changes is euthanasia, describe the method below :
* Location where euthanasia is to be performed:
* Justification for the changes:
3-2. CHANGES IN ANIMALS:
Numbers of animals
Species, Strain or Genotype
Conditions (sex and/or age) Change
Source or Method of Animal Acquisition
*Provide following information:
Source/
Genus / Species
name
Strain/Breed
Vender name
(if applicable)
Total Number
Sex
Approximate
Age
to be used in Entire
Project
* Justification for the changes in animals:
Page 3
3-3. JUSTIFICATION FOR CHANGES
: Provide justification for changes along with appropriate supplemental form for each category.
Changes will be made in:
(check applicable)
Anesthesia/Analgesia , Drug Administration
Surgical Procedure
Behavioral Testing Procedure
Pain and Distress
Blood/Tissue Collection
Bio-toxic Use
Breeding Colony
Please provide justification:
PRINCIPAL INVESTIGATOR’S ASSURANCE STATEMENT
I agree to abide by the Public Health Service (PHS) policy, USDA Regulations, the University of Albany Standard
Operation Procedures, the Guide for the Care and Use of Laboratory Animals, the Animal Welfare Act (AWA), all
federal, state and local laws and regulations and policies of the University of Albany.
Principal Co-Principal Investigator Certification
_____________________________________________
Principal Investigator Signature
Date:
Printed Name:
_____________________________________________
Co-Principal Investigator Signature
Date:
Printed Name:
University at Albany Veterinarian Certification
I have consulted with Principal Investigator and certify that:
1) all members of the research team involved in the care and use of animals have completed the
required occupational safety and health program requirements; and
2) all painful procedures have been reviewed for the proper use of anesthetics and pain-relieving
medications.
_____________________________________________
Veterinarian Signature
Date:
Antigone McKenna, DVM
Page 4