SUNY Downstate Medical Center
INSTITUTIONAL ANIMAL CARE AND USE COMMITTEE (IACUC)
Annual Protocol Review Form (check one):
First Annual Review
Second Annual Review
Submit this completed form with signature and attachments to mailto:IACUC@downstate.edu.
Date submitted:
IACUC use only
Date approved:
Protocol #:
Principal Investigator:
Department:
Protocol Title:
Funding Source:
Award # & project #:
Species Approved:
Project period:
Do you wish to continue the project for an additional year?
No
Yes
if NO, stop here, sign and submit form; if yes answer all questions below:
1.
Provide a summary of your progress over the past year toward the goals described in your protocol:
2. Note that all social species must be socially housed and provided environmental enrichment unless
there is an IACUC reviewed and approved scientific justification to do otherwise.
a. Do you currently have an IACUC approved scientific justification to single house animals on
this protocol
Yes
No - If yes, please describe the restrictions:
and provide
scientific justification for continued exemption:
b. Do you currently have an IACUC approved scientific justification for your animals NOT to
receive environmental enrichment on this protocol
Yes
No - If yes, please describe the
restrictions:
and provide scientific justification for continued exemption:
3. Enter the animal number from RPM for animals used over the past year for the following pain
categories: C:
D:
E:
; Based on the RPM animal census indicated above for
this protocol, will you need to amend your protocol to request additional animals beyond the IACUC
approved total number from the previous full protocol review?
No
Yes
if yes, how many
Provide the details of use and justification for the number requested:
4. Are there any changes in the objectives of this project?
No
Yes
if yes, provide details:
5. Are there ANY changes in the animal procedures prior to euthanasia of the animal? (ie,
species/strain; housing requirements; administration of drugs/treatments, biological hazard,
anesthesia, analgesia, euthanasia).
No
Yes
if yes, provide details:
Version 3.0 revised 11-2014
1
6. Have there been any unanticipated animal deaths over the past year?
No
Yes
if yes, how many
and give details:
7. Does this protocol include anesthetic agents?
No
Yes
if yes, give details in the following tables:
Drug(s) used for pre-anesthesia (restraint, tranquilization, and sedation):
Drug
Dose
(e.g. mg/kg)
Route of
administration
(e.g., IM, IV)
Duration of use or
total # of doses to be
given
Time between doses
Duration of use or
total # of doses to be
given
Time between doses
Duration of use or
total # of doses to be
given
Time between doses
Injectable Drug(s) used for anesthesia induction:
Drug
Dose
(mg/kg)
Route of
administration
Injectable Drug(s) used for anesthesia maintenance:
Drug
Dose
(mg/kg)
Route of
administration
Inhalant anesthesia for induction or maintenance:
Give the dose % (e.g.,
2 %) when using the
precision vaporizer
Induction or
maintenance?
Drug
Give the most
recent vaporizer
certification date
Reversal Agent(s):
Reversal Agents
Dose
(mg/kg)
Route of
administration
Duration of use or
total # of doses to be
given
Time between doses
Duration of use or
total # of doses to be
given
Time between doses
8. Does this protocol include analgesia?
No
Yes
if yes, give details:
Analgesic(s):
Drug
Dose
(mg/kg)
Route of
administration
9. Does this protocol include euthanasia?
No
Yes
if yes, give details:
Agent(s)/method
Version 3.0 revised 11-2014
Dose
Route of administration:
2
I hereby certify that within the past twelve (12) months I have searched the literature and found that the present
study is not unnecessarily duplicative of any other experiments and that scientifically viable alternatives are not
available. I also certify that there has been no changes in the animal care and use procedures for this study that
have not been reviewed and approved by the Institutional Animal Care & Use Committee prior to initiation.
Signature of:
Date:
Principal Investigator:
For IACUC use only:
Designated Member Reviewer:
Version 3.0 revised 11-2014
Date:
3
PAYMENT AUTHORIZATION FORM
It is my understanding that I will receive, on a monthly basis, the DCM invoice with charges for animal
purchases, per diem charges and any services performed by DCM (original bill) to be made by me for the
billing period. In accordance with the policy on “Eligibility to Use the SUNY Downstate Division of
Comparative Medicine (DCM) Animal Facility” I hereby authorize the Office of Research Administration to
encumber the awarded animal budget and pay monthly charges for animals (original bill) to the Division of
Comparative Medicine (DCM) from my protocol linked account and research grant noted below as the
animals are housed by my authority at this facility.
As the policy states, I understand that:
1.
If I disagree with the original bill in any given month, it is my responsibility to contact the DCM office
within two weeks to dispute that month’s charges (reconciled bill). Lack of communication confers consent to
pay the encumbered charges.
2.
My Research Foundation (RF) account (or other) will have the annual animal budget encumbered in
accordance with the above indicated policy and my monthly animal charges assessed against that encumbered
budget.
PRINCIPAL INVESTIGATOR:
Name (Please Print): __________
__________________________
Signature:________________________________Date:_________
Office Address:
Telephone #:
******************************************************
RF Project#:
RF Award#:
Sponsor:
Protocol Number:
Project Period From:
To:
******************************************************
FOR RESEARCH FOUNDATION ONLY
The Per Diem Animal Charges authorized above are appropriate charges to
Project #:
Award #:
Research Foundation Account Representative:______________________________
Version 3.0 revised 11-2014
4