Institutional Animal Care and Use Committee
(IACUC)
Office of Regulatory & Research Compliance MSC 309
(Phone) 437-3850 (Fax) 437-3855
(E-mail) iacuc@albany.edu
(Phone)
All protocol submissions/requests must have veterinary pre-review and be signed off by the University at
Albany Veterinarian prior to submission to the IACUC.
Investigators should contact the Veterinarian, Dr. Antigone McKenna (amckenna1@albany.edu) and
allow enough time for consultation. Submissions will not be considered for IACUC review until this has
been completed.
To avoid delays, please be sure to include all supporting, applicable attachments. Incomplete
submissions may be returned without review.
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Grant/Contract Application
Supplemental Forms
Any other documents referenced in the application
CITI Animal Care and Use Training Completion Reports
After veterinary consultation, submit completed and signed protocol requests to:
IACUC
Office of Regulatory & Research Compliance
MSC 309
University at Albany
Albany, NY 12222
IACUC@albany.edu
Voice (518) 437-3850 Fax (518)437-3855
An IACUC protocol may be approved for up to 365 days. In order to continue research thereafter, the
IACUC must review the approved project at interval of no less than once annually.
A protocol may receive up to 2 continuing annual reviews (i.e., maximum total approval time is three
years.) Once a protocol has reached the three-year mark, a new application must be submitted for de
novo review.
If you have any questions or need assistance in completing your application, please feel free to contact
the Office of Regulatory & Research Compliance at ORRC@albany.edu. Staff members are available to
assist and guide you through the review process.
Please remove this page before submitting protocol
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Institutional Animal Use and Care 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: ________________
IACUC Protocol Submission Form
Version 11.01.13
Initial
De novo submission (replaces previous protocol at end of 3rd year) - Previous protocol #
Project Title:
Anticipated Duration of Study:
(May state “upon IACUC approval”)
from
to
Principal Investigator (PI) Information:
The PI is the individual who has absolute responsibility for the overall conduct of all activities involving vertebrate
animals, including all technical, compliance and administrative aspects. The PI is responsible for controlling the
technical direction and academic quality of the project and for ensuring the project is carried out in compliance with the
terms, conditions, and policies of the sponsor, the IACUC, and the University at Albany.
Note: Copy of CITI Animal Welfare Training Completion Report must be attached for PI/Co-OI and all Key
Personnel including faculty advisor.
Principal investigator:
Name
Affiliation:
Position and Title:
Address:
Phone:
Department
University at Albany
College of Nanoscale Science and Engineering
The Neural Stem Cell Institute
Other (specify):
Faculty
Staff
Other specify : (
UAlbany Graduate Student*
) TITLE:
E-mail Address must be UAlbany domain email address
CITI Completion Report
Attached?
Yes
No
ORRC Use ONLY:
Verified :_____
Co-Principal investigator: (Individual designated to oversee research in PI’s absence and Faculty Advisor, when PI is Student)
Name
Affiliation:
Position and Title:
Department
University at Albany
College of Nanoscale Science and Engineering
The Neural Stem Cell Institute
Other (specify):
Faculty
Staff
UAlbany Graduate Student*
Other specify : (
) TITLE:
Address:
E-mail Address:
Phone:
CITI Completion Report
Attached?
Yes
No
ORRC Use ONLY:
Verified :_____
If there are additional co-investigators or Key Personnel, please complete and attach Additional Key Study Personnel
Form
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Sponsor Funded Research Studies
Federal regulations require those components of a grant application or contract proposal related to research
involving vertebrate animals are congruent with the application/proposal. University at Albany policy
extends this review to all funded protocols, whether funded internally or extramurally.
Is this research supported by funding?
Source:
Yes --
Internal
External
Sponsor/Agency/Department Name:
NO – SKIP TO SECTION “Study/Activity Information”
Funded Research Information
If you have applied for funding/have been funded, attach a copy of the grant/contract application
Status:
Awarded
Other (specify):
Award pending; JIT information has been requested
PI Name on Award:
Title of Award/Application:
COEUS Proposal Number:
University at Albany Office of Sponsored Funds Grant Administrator Name:
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Study/Activity Information
The following information is required for all projects and is required to be in layperson’s terms. Objectives must
be described in clear and short statement (DO NOT EXCEED 500 words) written in LAYPERSON’S
LANGUAGE (language that is understandable to a college undergraduate student).
DESCRIPTION
Provide a BRIEF description of the proposed research. The description should focus on THE PURPOSE OF
THE STUDY, as well as the PROCEDURES TO BE USED. AVOID SELF-CITATIONS (500 CHARACTER
LIMIT)
BENEFIT
Explain how the information gained in this study will benefit human or animal health, the advancement of
knowledge, and/or serve the good of society. This information is intended to inform the committee why it is
important to conduct this study.
Species and Numbers of Animals
SECTION 1: Project numbers of animals will be utilized in this project for a year.
Genus /
Species name
Strain/Breed
Source/
Vender name
Sex
(if applicable)
Approximate
Age
Type of
Animal*
Total Number*
to be used in
Entire Project
SECTION 2: Provide following information.
Justification for use of species:
Justification for use of more than one species (if applicable):
SECTION 3: Provide following information.
Are these animals experimentally naive?
Yes
No
*If No, provide a detailed history of each animal’s use previous to its use on this particular project. This includes
behavioral, surgical, drug use etc. Please provide this information by type of animal (Type of animal refers to the condition of
animals such as Adult, Pregnant, Neonates, Pups, Aged-animal, etc):
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SECTION 4: Describe how the number of animals needed for the study was determined.
SITE
Indicate Building name and Room number:

Location where animals are to be housed:

Location where procedures are to be performed :

Location where surgery is to be performed:
Endpoint of Animals
SECTION 1: Specify the experimental endpoint criteria (e.g. percentage of body weight loss or gain,
inability to eat or drink, behavior abnormalities, clinical symptomatology, or health abnormalities):
[If your lab has IACUC approved SOPs please cite the SOP number: SOP#
]
SECTION 2: Indicate what will happen to the animals at the end point of the project. Please designate the
number of animals for each category. If your lab has IACUC approved SOPs, please indicate SOP
number.
Endpoint Description
Euthanized [SOP#
]
Collect Samples (termination)
[SOP#
]
Transferred Another project
[SOP#
]
Returned to Colony
Number:
Please Specify:
Number:
Number:
Please Specify :
→if this item is checked, provide information and documentation(s) for the sales
Sold
Other [SOP#
Numbers of animals
Number:
Number:
]
Number:
Please Specify :
SECTION 3: EUTHANISIA
If the study involves euthanasia, please describe the method of euthanasia below:
[if your lab has IACUC approved SOPs please cite the SOP number: SOP#
]
Location where euthanasia is to be performed:
SECTION 4: If animals are to be sacrificed, describe the procedures to be used. (If pharmacologic agents
are to be used, indicate agent, dosage, and route of administration):
[if your lab has IACUC approved SOPs please cite the SOP number: SOP#
]
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Description of Animal Procedures
SECTION 1:
Please provide following information. Objectives must be described in clear and short statements (DO NOT EXCEED 500
words).
You are requested to conduct a literature search on section 2 (next page) for “Refinement”, which may relate to
alternatives and duplication sections. Information IS REQUIRED TO BE IN LAYPERSON’S TERMS.
Descriptions must be clear and brief sentence(s).
SCIENTIFIC JUSTIFICATION Explain why it is necessary to use animals for this purpose. What is the anticipated scientific
or educational benefit that may result from this use of animals? Indicate why it is necessary to use the number and type of
animals requested. Descriptions must be written in LAYPERSON’S LANGUAGE (language that is understandable to a
high school student).
ALTERNATIVES. Can mathematical/computer models, cell culture or tissue culture systems, in vitro systems, or other nonanimal method be used to reduce the number or eliminate the use of animals?
Yes
No
Specify:
DUPLICATION. Activities involving animals must not unnecessarily duplicate previous experiments. Provide written
assurance that the activities of this project remain in compliance with the requirement that there must be no unnecessary
duplication:
SECTION 2:
REFINEMENT
To reduce the number or eliminate the use of animals, federal law requires alternatives to non-animal method /
procedures if available. You are requested to conduct a literature search to determine that either (1) there are no
alternative methodologies, by which you can conduct this study, or (2) there are alternative methodologies, but
these are not appropriate for your particular study. “Alternative methodologies” refers to reduction, replacement,
and refinement of animal use, not just animal replacement. DO NOT attach print-outs of the searches.
ALTERNATIVES TO THE USE OF ANIMALS FOR PAINFUL PROCEDURES
Please provide 3 separate database searches. The date ranges for each database search are also required. Please
provide the following information for each procedure. Duplicate the table as often as required.
Procedure:
Databases searched (minimum of 3): e.g. Medline, Biosis, Agricola
Date search conducted:
Date range of search (month/year): From:
Keywords used:
To:
Procedure:
Databases searched (minimum of 3): e.g. Medline, Biosis, Agricola
Date search conducted:
Date range of search (month/year): From:
Keywords used:
To:
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Procedure:
Databases searched (minimum of 3): e.g. Medline, Biosis, Agricola
Date search conducted:
Date range of search (month/year): From:
Keywords used:
To:
Other sources used in addition to database searches:
Current books/journals (specify):
Professional communication with colleagues (specify):
Animal Welfare Information Center (AWIC-http://www.nal.usda.gov/awic/):
Other (specify):
SUMMARY OF FINDINGS:
SECTION 3: Other specific information relate to animal procedure: if your lab has IACUC approved SOPs
please cite the SOP number also.
1.
Yes
No
dying far, etc?
2.
Yes
No Will this project involve other non-surgical procedures (e.g. husbandry procedures, tail biopsies,
etc)? : if yes, specify the method:
3.
Yes
No
Will this project involve animal identification methods such as ear tag, tattoo, collar, pen marks,
: if yes, specify the method:
Will this project involve infectious disease?
4.
Yes
No Will this project involve potential stresses (e.g., food or water deprivation, noxious stimuli,
environmental stress)?
5.
Yes
No Will this project involve any of the following: (i) recombinant DNA (include transgenic animals);
(ii) human or animal pathogens; (iii) biological toxins; (iv) administration of experimental biological
products or (v) radioactive materials. If yes, mark appropriate item(s).
Recombinant DNA (include transgenic animals)
Biological toxins
Human pathogens
Administration of experimental biological products
Animal pathogens
Radioactive materials
Please note: If you checked any of the above boxes, you may need to submit protocols to the University
Biosafety Officer, Institutional Biosafety Committee, Institutional Review Board and/or Radiation Safety
Committee.
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Supplement Forms Check List
Indicate below whether your project involves any of the following: For each item checked, complete the
appropriate SUPPLEMENTAL FORM(S) and submit them along with a completed primary form.
Additional information may be attached to supplement the required information as necessary.
SUPPLEMENT
FORM
CHECK
If
applicable
CONTENTS
Tissue/Blood collection in survival procedures
Tissue/Blood collection in non-survival procedures
1: Collection or Receipt of
Biological Samples
Tail Biopsy in mice and rats
Samples (other than tail) from birds, rats of the genus rattus, and mice of the genus
mus.
Warm-Blooded Animals other than birds, rats of the genus rattus, and mice of the
genus mus
NOTE: “samples” include genetically modified organisms, body fluid, tissues, blood, and
pathogens.
2: Behavioral Testing
Single procedure
3: Pain / Distress
Physical Restrain
Food/Water deprivation
Shock
The use of infectious agents or biological toxins
Other
Multiple procedures
NOTE: other possible pain/distress items as follow; cold/hot exposure, forced exercise,
uncontrollable aversive stimuli; if more than “momentary” pain/distress is involved, PI must
submit pain/distress form. Please read detail for page 1 of Form 3 for USDA category.
If your protocol involves any kind of drugs, please provide the list on the first page of
FORM 4.
4: Drug Administration
5: Biological Toxins
(include controlled
substance) Administration
Administration of drugs used for sedation, anesthesia, analgesia, or
tranquilizers.
Use of Paralyzing / Neuromuscular Blocking Agents
Administration of controlled substances other than sedation, anesthesia,
analgesia, paralyzing agents (e.g., narcotics, carcinogens, infectious agents, etc.)
Use of biological, chemical, toxic, or radioactive substances
Use of Narcotics, Carcinogens or other controlled substances
Single procedure
Multiple procedures
6: Surgical Procedures
Terminal
7: Special Animal Care
Requirements
8: Breeding Colony
Non-terminal
Housing: Caging, quarantine, light cycle, temperature/humidity control etc.
Satellite Housing: Outside of the animal facility more than 12 hrs
Care of animals by anyone other than animal care staff
Animal Transfer :
from the outside
to the outside
Establishment and Maintenance of a breeding colony
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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:
Dean/Department Chair/Center Director Certification
_____________________________________________
Department Chair Signature
Date:
Printed Name:
Dept:
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
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