APPLICATION FOR MINOR AMENDMENT TO AN EXISTING ANIMAL PROTOCOL
Fill out this form if you are proposing minor changes to a protocol: for example changes in personnel, substitution
of one strain of animal for another, minor procedure that does not affect the care and welfare of the animal(s).
If you wish to make significant changes, you should submit a major amendment. The examples of significant
changes include changes in study objectives, from non-survival to survival surgery, species, animal numbers
exceeding 10% of the original approval, principal investigator, anesthetic agent, use of analgesic, biohazard
agent, duration, frequency or number of procedures performed
Submit completed, signed form to Angela Muise in the Office of Research. Call Angela at 508.856.5384 with
questions regarding this form. If you are unsure of whether your proposed amendment is major or minor, call the
IACUC Director, Samuel Varghese, Ph.D., at 508.856.5416
1. Docket #: A2. Name of PI:
3. Dept.:
4. Phone #:
5. Primary Contact Person:
Phone #:
Campus/Building:
6. TITLE OF PROJECT:
7. DESCRIPTION OF MINOR CHANGES:
a. Changes in Personnel: (Mark those that apply with an X and provide details below)
o *By signing below, you are acknowledging that you have read, understood and agreed to comply with the
UMMS IACUC approved protocol listed above.
o
†First time UMMS animal user (those who are new to UMMS or those UMMS personnel going to use animals
for the first time) will receive IACUC approval to work with animals ONLY after (1) completing the On-line
Animal Training Requirements, (2) receiving Health Clearance and (3) filling out a New Personnel Form. For
details, refer to the CHECKLIST FOR NEW ANIMAL USER (link below):
http://inside.umassmed.edu/uploadedFiles/Animal%20facility%20access%20checklist.doc
§
Name
Years of
experience
with the
technique in
species to be
used
*Signature
Enter “A”
if adding
“O” if
omitting
†First time
animal
user at
UMMS
Yes/No
≠ Occupational
Health
Yes/No
Indicate here if any of the individuals above is a co-investigator:
§
If adding personnel with <1 year of experience, indicate who is responsible for training and/or supervision
Indicate if any of the above individuals will be performing survival surgery for the first time (Those who
never performed survival surgery MUST receive Surgery Training from the Animal Medicine Department and
submit documentation to the IACUC office before performing surgery: contact Van Gould at extension 66811 or
Suzanne Wheeler at extension 62363 for Surgery Training)
≠Health Clearance from the Employee Health service and other Occupational Health and Safety Training as needed
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Rev 10/08
b. Changes in Procedures:
If you are proposing to make minor procedural changes: use this space to describe them. Please be sure to
describe what was previously approved as well as the requested change.
c. Changes in Numbers of Animals:
Species
Pain level
B
C
D
E
Number
originally
approved
Number you
wish to add†
†
No more than 10% of number of animals originally approved will be accepted. Any amount over that number will
require a major amendment.
Justification of additional animals to be used:
(Please attach an additional sheet of paper to this Amendment if needed.)
d. Change of strain/breed of animal:
Current Strain/Breed:
Strain or breed you wish to add/substitute:
e.
Change in Hazardous Agent:
Does the change that you are proposing alter your use of (indicate Y or N):
Radiation
Chemical Hazards
Human/non-human primate cells
Recombinant DNA Technology
Infectious Agents
If you answered “Y” to any of the above, briefly describe the changes:
8. Signatures:
PRINCIPAL INVESTIGATOR : __________________________________________DATE : ________
(For IACUC Use Only)
INSTITUTIONAL ANIMAL CARE AND USE COMMITTEE REVIEW
Veterinary Review _____________________________________________________________
IACUC Reviewer
____________ ________________________________________________
Approved on: ______________________________ (DATE)
_____________________________________________________________________________
Chair/Vice Chair, Institutional Animal Care and Use Committee
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