ORC Use Only:
Protocol #:
Approval:
IACUC Application
Breeding Protocol Form
Instructions: Please complete all sections of this core protocol application and all applicable appendices and submit with Principal Investigator
signature to the Office of Research Compliance (ORC). All new and continuing applications will undergo Attending Veterinarian consultation and
review by ORC prior to IACUC review. Please allow 4-6 weeks from time of submission for IACUC review.
Form completion instructions: To populate a box simply click once on the box to show the “X.” To uncheck box, click on it once
more to remove “X.” For narrative responses, click on the prompt text (“Click here to enter text”) and begin typing.
GENERAL INFORMATION: Is this a new or continuation application? ☐ New application ☐ Continuation application
Previous protocol #: Click here to enter text. (e.g., 10-001)
Protocol Title: Click here to enter text.
Principal Investigator: Name: Click here to enter text. 800 #: Click here to enter text.
Department: Click here to enter text.
Campus Address (Building and room #): Click here to enter text.
Email: Click here to enter text. Campus Phone: 7 - Click here to enter text. Emergency phone: Click here to enter text.
Co-Investigator: Name: Click here to enter text.
800 #: Click here to enter text.
Department: Click here to enter text.
Campus Address (Building and room #): Click here to enter text.
Email: Click here to enter text. Campus Phone: 7 -Click here to enter text.
Emergency phone: Click here to enter text.
☐ FUNDED? For all funding sources listed below, submit a copy of the Research and Design Methods
and Vertebrate Animal sections of your proposal, scope of work, or contractual agreement with this
application for grant/protocol congruency review.
☐ N/A Not Funded
NOTE: If using internal funds (i.e., University or departmental), complete only the “source” and “status”
areas below.
Sponsor #1:
Name: Click here to enter text.
Status of funding: ☐ Proposal submitted ☐ Just-in-Time notification ☐ Funds awarded/existing funding ☐ Pending ☐ Other
Specify Click here to enter text.
Source of funding: ☐ Federal ☐ State ☐ University ☐ Private/Foundation ☐ Other Specify Click here to enter text.
Funding Period: Click here to enter text. to Click here to enter text.
NORM proposal #: Click here to enter text. (e.g., 14-0500)
Sponsor #2:
Name: Click here to enter text.
Status of funding: ☐ Proposal submitted ☐ Just-in-Time notification ☐ Funds awarded/existing funding ☐ Pending ☐ Other
Specify Click here to enter text.
Source of funding: ☐ Federal ☐ State ☐ University ☐ Private/Foundation ☐ Other Specify Click here to enter text.
Funding Period: Click here to enter text. to Click here to enter text. NORM proposal #: Click here to enter text. (e.g., 14-0500)
Should animals be found sick or dead, please provide an emergency contact name, phone number and email address:
Emergency Contact: Click here to enter text.
Email address: Click here to enter text.
Phone number: Click here to enter text.
Breeding Protocol Form
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Section I: Personnel
1. Provide the following information for all personnel who will be conducting animal activities on this project.
To add a row, in the “Layout” menu in Word, select “Insert Below” and copy and paste contents of previous row into
new one. TIP: Do not use first row to copy.
Personnel
Techniques
Techniques
FOR IACUC
OFFICE
ONLY
FOR IACUC
OFFICE
ONLY
FOR
IACUC
OFFICE
ONLY
Name: _____________________
Select all that apply for
this project/protocol.
(Continued)
CITI Training
Completed?
Vivarium
Orientation
Completed?
Enrolled
in Occ
Health
Program?
(Last Name, First Name, Middle Initial)
800 #: _____________________
Proposed Role(s) on Project
(Select all that apply)
☐ Principal Investigator
☐ Co-Investigator
☐ Animal Handler
☐ Animal Orderer
☐ Official Contact
☐ Emergency Contact
☐ Surgeon
☐ Temporary Personnel
☐ Other Specify:
Click here to enter text.
Name: _____________________
(Last Name, First Name, Middle Initial)
800 #: _____________________
Proposed Role(s) on Project
(Select all that apply)
☐ Principal Investigator
☐ Co-Investigator
☐ Animal Handler
☐ Animal Orderer
☐ Official Contact
☐ Emergency Contact
☐ Surgeon
☐ PI NOT DOING ANIMAL
WORK
☐ CONSULTING ONLY – no
animal handling
☐ Handling & restraint
☐ Administration of injectable
anesthetics & analgesics
☐ Administration of inhaled
anesthetics & analgesics
☐ Breeding husbandry
☐ Ear notch/ear tag
☐ Weighing / measuring
☐ Cardiac puncture
☐ Cervical dislocation w/
anesthesia
☐ CO2 euthanasia
☐ Decapitation w/ anesthesia
☐ Exsanguination
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐ PI NOT DOING ANIMAL
WORK
☐ CONSULTING ONLY – no
animal handling
☐ Handling & restraint
☐ Administration of injectable
anesthetics & analgesics
☐ Administration of inhaled
anesthetics & analgesics
☐ Breeding husbandry
☐ Ear notch/ear tag
☐ Weighing / measuring
☐ Cardiac puncture
☐ Cervical dislocation w/
anesthesia
☐ CO2 euthanasia
☐ Decapitation w/ anesthesia
☐ Exsanguination
☐ Aseptic technique
☐ Incision site prep
☐ Instrument prep
☐ Suture placement /removal
☐ Intradermal injection
☐ Intramuscular injection
☐ Intraperitoneal injection
☐ Intravenous injection
☐ Oral gavage
☐ Retro-orbital bleed
☐ Retro-orbital injection
☐ Saphenous bleed
☐ Tall clip bleed
☐ Other Specify:
Click here to enter text.
Aseptic technique
Incision site prep
Instrument prep
Suture placement /removal
Intradermal injection
Intramuscular injection
Intraperitoneal injection
Intravenous injection
Oral gavage
Retro-orbital bleed
Retro-orbital injection
Saphenous bleed
Tall clip bleed
Other Specify:
Click here to enter text.
☐ YES
☐ YES
☐ YES
Date:_________
Date:_______
Date:_____
☐ NO
☐ NO
☐ NO
☐ YES
☐ YES
☐ YES
Date:_________
Date:_______
Date:_____
☐ NO
☐ NO
☐ NO
☐ Temporary Personnel
☐ Other Specify:
Click here to enter text.
Breeding Protocol Form
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SECTION II: Overview of this study
1. Purpose: Briefly describe the overall purpose of this animal use study. This should typically be less than 75 words
and be easily understood by nonscientists (e.g., ‘We propose to breed these animals to be used in a study to test the
effectiveness of a new class of drugs’).
Click here to enter text.
SECTION III: BREEDING
1. Justification for Breeding Animals
1. Could the animals you plan to breed be purchased from commercial sources in the required number?
☐ No. The animals are not available commercially in sufficient number.
☐ Yes. The animals are available commercially. Please describe the rationale for breeding these
animals:
Click here to enter text.
2. Please identify the source of breeders:
☐ Colony managed by a UNC Charlotte investigator. Source protocol#: __ __ - __ __ __
☐ Obtained from another institution or non-UNC Charlotte investigator. Identify source:
Click here to enter text.
☐ Purchased from a vendor (I.e. Charles River, Harlan, etc.) Identify vendor:
Click here to enter text.
2. Breeding Colony Species and Numbers: On the chart below, indicate the numbers of breeders required, and provide
estimates for the numbers of offspring expected and the expected disposition of those offspring by strain,
transgene, knockout or knock in. Since protocols have an approval period of 3 years, please provide total
anticipated numbers for a 3-year period.
Species
Strain /
Transgene /
KO
# Male
Breeders
Required
# of
Female
Breeders
Required
Estimated #
of Offspring
transferred
to another
protocol
Column A
Estimated #
of Offspring
euthanized
prior to
weaning
Column B
Expected Total
# of Offspring
(Add columns
A-B)
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2. Disposition of Breeders and Unneeded Offspring
a. Disposition of Retired Breeders: Please select the method of disposition:
☐ Euthanasia according to protocol Complete item c below.
☐ Used in experiments. Describe:
Click here to enter text.
☐ Other. Describe:
Click here to enter text.
b. Disposition of pre-weanling offspring not required for experiments/breeding: Please define the method
of disposition for offspring which are not being used as part of this protocol:
☐ Euthanized as unneeded or wrong genotype Complete item c below. (NOTE: Genotyping animals
Breeding Protocol Form
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by tail clip, ear punch, or other method is considered a “use.” Do not list these animals as
“euthanized as unneeded”)
Provide justification for the euthanasia of surplus animals (why are these animals not candidates for
use on other studies or for Vivarium use?):
Click here to enter text.
☐ Transfer to another protocol
Protocol #: Click here to enter text.
If the transfer of animals is to a non-UNC Charlotte researcher, please describe the considerations
to be taken in preparing animals for export (i.e. health status, shipping logistics, permitting if
applicable, how animals will be confirmed to be in good health upon arrival at final destination,
etc.). Please also confirm that you will consult with the Attending Veterinarian / Director of
Laboratory Animal Resources (DLAR) within 2-3 weeks in advance of shipment.
Click here to enter text.
☐ Other Specify: Click here to enter text.
c. Euthanasia for breeders and/or offspring: Methods should be in accordance with the American
Veterinary Medical Association’s (AVMA’s) Guidelines for the Euthanasia of Animals. For studies
involving rodents please refer to the Rodent Euthanasia Guidelines for acceptable methods in
consultation with the AV.
Note on drop down lists: Choose only one item per row. To unselect an option simply click on “Choose
an item.” Complete other cell entry in the table by typing in information.
Method of
Euthanasia
Species
Dose and Route of
Administration (for
Use of Anesthetics)
Method to Ensure
Death
If “Other” specify
method below.
Click here to enter text.
Choose an item.
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For use of cervical dislocation or decapitation without anesthesia, indicate which method will be used and
provide scientific justification for your selection:
☐ Cervical dislocation with no anesthesia Scientific justification:
Click here to enter text.
☐ Decapitation with no anesthesia Scientific justification:
Click here to enter text.
3. Breeding Plan
d. The breeding plan will consist of:
☐ Monogamous (single female and single male per cage)
☐ Harem (single male and multiple females). Please indicate among the options provided below which
scheme will apply:
☐ Males will be removed once females are confirmed pregnant
☐ Females will not be bred again until the offspring are weaned
Breeding Protocol Form
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☐ Individual pregnant females will be moved to new cages prior to delivery of offspring
☐ Females and their litters will be moved to larger cages to provide required floor space
NOTE: Per the Cage Compliance Policy, the accommodation of harem breeding in larger cages is considered a
deviation from standards set forth in the Guide and therefore an exception request should be submitted for
IACUC review/approval. Please complete Appendix A: Exceptions or Deviations from the Guide or IACUC
policy to submit a request for larger caging to accommodate harem breeding with multiple litters in one
cage.
4. Weaning Schedule: Rodents will be weaned:
☐ 21 days of age
☐ 22 days of age or later (specify strains to be affected and justification for extending weaning period
beyond 21 days): Click here to enter text.
NOTE: Normal weaning typically occurs around 21 days. For any variations in weaning period please consult
with AV/DLAR.
5. Special Care Requirements: Certain strains may require special provisions to assure their well-being. Please specify if
any special care provisions are required to facilitate the survival and development of these offspring.
☐ Special care beyond routine animal care is not necessary
☐ Special care is necessary to keep these animals healthy. The required care is as follows (describe):
Click here to enter text.
6. Genotyping: Please indicate below whether genotyping will occur as part of your breeding plan and if so by which
method.( Please refer to the Rodent Genotyping SOP for further guidance and allowable methods for genotyping.)
☐ Genotyping is not necessary for this protocol OR
☐ Genotyping will be performed on tissue obtained by the method(s) identified below:
☐ Tail clipping as follows: (NOTE: A maximum of 5 mm of tail can be clipped from the tail of a single
animal). Select one option below:
☐ One tail clip prior to 17 days of age
☐ Total number of clips: ___ (NOTE: Consult with the Attending Veterinarian if proposing to tail clip
animals more than once at under 17 days of age. A maximum of 5 mm of tail can be clipped from
the tail of a single animal).
☐ Tail clipping will occur once in animals under 17 days of age, but may need to be done a second
time on animals over 17 days of age per the Genotyping SOP. Provide brief justification for tail
clipping of animals over 17 days of age. NOTE: this would be a deviation from standards. Please
complete Appendix A: Exceptions or Deviations from the Guide or IACUC policy to submit a request
for second tail clipping for older animals.
Click here to enter text.
Provide information as prompted in the table below on the anesthetic/analgesic to be used for tail
clipping of animals over 17 days of age:
Note on drop down lists: Choose only one item per row. To unselect an option simply click on
“Choose an item.” Complete other cell entry in the table by typing in information.
Breeding Protocol Form
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Drug Name
Dose
Route
Frequency of
Administration
(indicate pre- or
post-procedure if
applicable)
Anticipated
Duration of
Effect (in
minutes, hours
or days)
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Describe monitoring procedures to ensure adequacy and safety of anesthesia or tranquilization: Click
here to enter text.
Describe monitoring procedures for recovery from anesthesia or tranquilization: Click here to enter text.
☐ Ear punch per the Rodent Genotyping SOP
☐ Blood collection – Provide information in the table below:
Collection Site
Method
Amount Drawn
Frequency of
Collection
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7. Transgenic / Knockout Animals
a. Briefly describe the genetic alteration of interest:
Click here to enter text.
b. The phenotypic expression of this genetic alteration will likely result in:
☐ No morphologic or functional impairment
☐ Increased early mortality
☐ Physical impairment as follows:
Click here to enter text.
☐ Functional deficit as follows:
Click here to enter text.
☐ Possible impairments that are currently unknown. Please describe the monitoring plan that will be
used for early detection of potential impairments:
Click here to enter text.
Section IV: Animal Identification, Husbandry, and Monitoring
1. Will any markings be used to identify animals? ☐ YES ☐ NO
If YES, please indicate method of animal identification:
☐ Ear tagging
☐ Ear notching / ear punch
☐ Tattooing
Breeding Protocol Form
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☐ Non-toxic marker or pen
☐ Microchip
☐ Identification via tank/cage cards
☐ Other Specify: Click here to enter text.
2. Will standard enclosures (cages, tanks for aquatic animals) be used? ☐ YES ☐ NO
If NO, please indicate special housing conditions:
☐ Ventilated rack system
☐ Sterile housing for immunocompromised animals
☐ Metabolic cages
☐ Single housing of animals (NOTE: Single housing of social animals is considered a deviation from the Guide
and should be noted in Appendix A: Requests for Exceptions/Deviations from the Guide or IACUC policy.)
☐ Other Specify: Click here to enter text.
3.
Who will be primarily responsible for animal monitoring (including overnights, weekends and holidays)?
(NOTE: Arrangements should be made with the Attending Veterinarian for care of animals and development of a monitoring plan.)
☐ Research personnel only
☐ Vivarium staff and research personnel
4. Please specify how animals will be monitored. What complications could arise and how will monitoring address
these complications?
Click here to enter text.
5. Will special handling of sick or dead animals be required? ☐ YES ☐ NO
If YES, please specify and provide justification. Refer to the Reporting and Handling of Sick/Dead Animals SOP:
Click here to enter text.
6. Are special diets, additives to food/water and/or antibiotics administered?
☐ YES
☐ NO
NOTE: Food/water restriction or reduction is considered a deviation from standard husbandry guidelines in the
Guide. Please provide a brief description below and complete Appendix A: Requests for Exceptions/Deviations
from the Guide or IACUC policy with this application.
If YES, provide a brief description here: Click here to enter text.
Section V: Endpoints (Study and Humane)
1. Do you anticipate any complications in the breeders or offspring?
☐ NO. Animal health complications are not expected.
☐ YES. Animal health complications may occur.
If YES, answer a-c below:
a. Describe the health complications that are anticipated:
Click here to enter text.
b. Describe the plan for detecting the development of complications and their routine management:
Click here to enter text.
c. If animals experience complications that are not resolved by the above management plan, specify the
action(s) that will be taken (select all that apply):
Breeding Protocol Form
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☐ Euthanize the animal
☐ Seek veterinary care
☐ Withdraw the animal from the breeding protocol for treatment and recovery according to the
following plan (describe):
Click here to enter text.
2. HUMANE ENDPOINTS - Which humane endpoints will be used? (select all that apply):
☐ Loss of weight exceeding 20% of normal body weight
☐ Inappetance
☐ Prolonged diarrhea for 12 hours
☐ Hunched posture
☐ Non-weight bearing
☐ Porphyrin staining around eyes
☐ Ungroomed / unkempt – ruffled fur
☐ Loss of body temperature / hypothermia (evidenced by continuous shivering longer than 8-10 hours)
☐ Unsteady gait
☐ Decreased body condition score – refer to the Rodent Body Condition Score Guidelines for more information
☐ Depression for over 72 hours
☐ Dehydration
☐ Vocalizations / respiratory difficulty
☐ Discharge from eyes, nose, perianal areas
☐ Other Specify: Click here to enter text.
OTHER SPECIAL CONSIDERATIONS: If this project will involve any of the following, please indicate by checking the
corresponding box. Then complete the appropriate appendix and submit along with this application form.
☐ Requests for Exceptions / Deviations to the Guide or IACUC policy – Please complete Appendix A
☐ Confidential or Proprietary Information – Please complete Appendix B
Breeding Protocol Form
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Principal Investigator Assurances / Signature Page
Protocol Title: Click here to enter text.
Principal Investigator: Click here to enter text.
By my signature below, I certify that I agree to the following statements:
I.
I certify that I am familiar with and assure compliance in this protocol with the legal standards of animal care and use established under
the Federal and State laws and the policies on animal welfare of the National Institutes of Health and UNC Charlotte;
II.
I assume responsibility for ensuring that all personnel working with animals on this project are familiar with and are trained in relevant
animal procedures and that they will comply with established laws and policies regarding animal care and use;
III.
I certify that all individuals working with animals on this project will:
a.
b.
IV.
Complete online training using the CITI system as required by the IACUC;
Enroll in the Occupational Health program by completing a Health History Form and submitting it to the Occupational Physician
for medical clearance and submitting annual health updates;
c. Complete initial Vivarium Orientation with the Attending Veterinarian, Director of Laboratory Animal Resources (DLAR), or their
designees (if Vivarium access is required for their work); and
d. Attend once per academic year an informational seminar and provide an annual health update as conditions for continuous
good standing in the animal care/ use program; and
e. Follow all applicable regulations and guidelines of the Vivarium as well as IACUC-approved policies, guidelines, and/or Standard
Operating Procedures (SOPs).
I certify the following: the research proposed herein is not necessarily duplicative of previously reported research; appropriate nonanimal alternatives for this research do not exist; no alternatives to the potentially painful/distressful procedures conducted in this
project exist. I have indicated methods used to make these determinations in the appropriate section of this animal care/use application;
V.
I will secure IACUC approval before changing procedures or personnel associated with this study (including adding or removing
personnel);
VI.
I assure that I and personnel under my direct supervision will use the animals acquired for the activity described herein solely for said
purpose. I also certify that if live animals are shared with other PIs or are used in any procedure other than those described in this
application, I will provide the details in the form of a written amendment to the original application prior to their use;
VII.
I acknowledge that veterinary care will be administered to moribund animals or animals experiencing more than momentary or slight
pain and distress. Vivarium staff or the Attending Veterinarian will attempt to contact me regarding the care and treatment of a
moribund animal, but will institute treatment or euthanasia, as needed, if I cannot be reached quickly;
VIII.
I assure that I will notify the IACUC and the Attending Veterinarian regarding any unexpected study results that adversely impact the
animals, including any unanticipated pain or distress, morbidity or mortality.
IX.
I agree if at any time any member of the research team or their immediate family members have financial interest in, receive personal
compensation from, or hold a position in an industry sponsoring this study or otherwise have a personal conflict of interest, I will
complete or update my conflict of interest records in the “Activities, Interests, and Relationships” (AIR) online system and will notify
anyone on my research team to do the same if warranted.
X.
I assure the IACUC and UNC Charlotte that the general procedures involving animals described in my grant proposal, scope of work, or
contract has been described in this application and such documents have been submitted for IACUC grant/protocol congruency review;
XI.
I assure that I have read the AVMA Guidelines for Euthanasia of Animals and understand how it applies to the animals I will be using for
research or testing purposes per this application; and
XII.
If I use any biological, chemical, and/or radiological hazards in animals I will contact the Office of Research Compliance for information on
how to proceed.
NOTE: Consultation with the Director, Laboratory Animal Resources (DLAR) regarding space allocation is recommended prior to submission of an
application. IACUC approval of an application does not assure Vivarium space availability. Also, please contact the Vivarium for a pre-study strategy meeting
prior to ordering animals to discuss availability of housing.
NOTE: Cell lines that have been passaged in animals or maintained using animal serum may contain murine viruses that can alter the outcome of the study
and may cause an outbreak of disease among other mice. ATCC does not screen cell lines for murine pathogens. Cell lines that have been passaged in
animals or grown in media containing rodent serum should be tested for murine pathogens prior to use in animals. Please contact the Vivarium for more
information on testing of your cell lines.
__________________________________________
PI Signature
___________________________________
Date
Breeding Protocol Form
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