Research Office
Research Hub, Building C5C East
MACQUARIE UNIVERSITY NSW 2109
Animal Ethics Secretariat
Phone +61 (0)2 9850 7758 / 4456
Email
Animal.Ethics@mq.edu.au
Macquarie University
Animal Ethics Committee
ANIMAL-DERIVED TISSUE USE (ONLY) FORM
(October 2013)
OFFICE USE ONLY
Date received:
ARA no.:
AEC meeting date:
The purpose of this form is to assist the AEC with oversight of the use of animal tissues (only) for research.
Please provide information consistent with this purpose (ie. detailed descriptions of in vitro methodology are not
required).
Use this form for research and/or teaching involving the use of animal-derived tissues, in the absence of live
animals.
Instructions for completion of this form:
Answer all questions in full. The boxes will expand as you type. For highlighted boxes Double Click to check.
Use lay terms where possible. Your responses should be directed to an educated, non-scientific audience.
Instructions for submission of this form:
This report should be submitted to:
Animal Ethics Secretariat at the above email address
1. Details of the Protocol that covers the collection of the tissue from
live animals
ANIMAL ETHICS COMMITTEE:
PROTOCOL REFERENCE NUMBER:
PROTOCOL TITLE:
PRINCIPLE INVESTIGATOR:
2. Animal Details (please complete)
ANIMAL SPECIES:
STRAIN:
SEX:
AGE:
3. Tissue Details (please complete)
TYPE:
QUANTITY:
4. Providence (please complete)
Please select one of the following:
The tissue has already been collected and stored under a previously approved research protocol
that is now expired.
The tissue is to be collected and supplied under a current, approved research protocol
Other
FURTHER DETAILS:
Please attach the original Animal Ethics Application and Approval for the research protocol
under which the tissue was/is to be collected.
5. Biosafety and WH&S
All projects must have approval from the either Biosafety Committee [for Genetically Modified Organisms
(GMOs)], and/or the Biohazards Committee for all work with hazardous materials, including all work with
animals or animal tissues or products, prior to the commencement of research.
Are any procedures dealing with tissues from GMOs?
Yes, GMOs
Go to (a), (b) and to (c)
No, biohazards only
Go to (b)
(a) Please fill out the forms obtained on the biosafety website (below) and check this box
http://www.research.mq.edu.au/for/researchers/how_to_obtain_ethics_approval/biosafety_researc
h_ethics/forms
(b) Please fill out the Biohazard Risk Assessment Form found on the Health and Safety
Website (below) and check this box
http://www.hr.mq.edu.au/HealthAndSafety/PoliciesFormsGuidelines/OHSOperationalInstruction.html
For further information, visit the Biosafety website, and check the flowchart, at
http://www.research.mq.edu.au/for/researchers/how_to_obtain_ethics_approval/biosafety_research_et
hics/application_process
(c) Please complete the phenotype report form found on the animal ethics website (below)
and check this box
http://www.research.mq.edu.au/for/researchers/how_to_obtain_ethics_approval/animal_ethics/forms
WH&S Declaration
I confirm that:
All personnel involved with this project have been informed of the risks associated with working
with animals in this project (e.g. zoonoses) and measures have been taken to mitigate these risks
Appropriate measures for containment, disposal and decontamination of biohazardous material (if
applicable) have been established
Signed:
Date:
8. Requesting Investigator Details (please complete)
NAME:
INSTITUTION:
DEPARTMENT:
CONTACT DETAILS:
Signed:
Date:
9. Supplying Investigator Details (please complete)
NAME:
INSTITUTION:
DEPARTMENT:
CONTACT DETAILS:
I confirm that:
the tissues to be used, as detailed in this Form, are genuinely spare and are not collected in
addition to the requirements of the original supplied, AEC-endorsed protocol.
Signed:
Date: