Institutional Animal Care & Use Committee
To: Institutional Animal Care and Use Committee
Re: Adverse Event Report
PI Name:
Protocol Number:
Project Number, if applicable:
1. Describe the adverse event and include number of animals lost and the total numbers of animals
undergoing the study associated with the adverse event up to this point (this is not necessarily the
approved number of animals, since all animals may not be enrolled in the study yet).
2. Include a brief description of the study to this point – agents administered (route, volume, time frame
over the course of the study), surgical procedures, miscellaneous procedures.
3. Incorporate the above events into a time line (administration of agents, surgery, miscellaneous related
to the time of death – same day, within a week, extended period of time later)
4. Indicate steps taken following death – necropsies performed/by whom, evaluation of surviving
animals, re-evaluation of the study group affected to determine potential causes for death.
5. Definite or proposed cause for adverse event.
Proposed plan for future animals related to the above findings.
Please submit this form to iacuc@tulane.edu. If the PI is not the sender, he/she must be copied on the
email. The adverse event will be discussed at the next IACUC meeting. The committee may request
additional information or request an amendment be submitted to account for any proposed changes.
Downtown Campus
Primate Research Center
1430 Tulane Ave., Box 8423 New Orleans, LA 70112 tel 504.988.6868 fax 504.988.1445