ANIMAL ETHICS COMMITTEE - FORMS Do not submit this page INFORMATION FOR APPLICANTS 1. Ensure that you are using the most current version of the form. 2. Hand written applications are not accepted. 3. Please ensure that you are aware of the procedures http://research.curtin.edu.au/guides/animal.cfm 4. Applications will only be processed when all copies are received (both hard and electronic). LODGING YOUR APPLICATION You must submit: 1. One (1) signed hardcopy of the application and all supporting documentation to: In Person The Secretary Animal Ethics Committee Office of Research and Development Curtin University Building 100, Level 1 West Bentley WA 6845 Posting The Secretary Animal Ethics Committee Office of Research and Development Curtin University GPO Box U1987 Bentley WA 6845 2. A full electronic version of the application and all supporting documentation submitted to ethicsapplications@curtin.edu.au. Please ensure all attachments are clearly labelled and in pdf format (if possible). FILLING IN YOUR APPLICATION This form is set up as a series of tables and check boxes require when you type and by pressing the Enter key. Press the Tab key to move between fields (questions), or use your mouse to click in at the front of the cell (a black square will appear – you can then start typing). To mark a check box, simply click and a box and it will look like this again. Do not submit this page with your application. Document1 . The table will enlarge to the size you . To ‘undo’ the check, click 1 of 20 ANIMAL ETHICS COMMITTEE Application to Undertake Research Involving Animals Office use only: Submission Number _________ Approval Number _____________ PRIVACY STATEMENT At Curtin University, the privacy of our students, staff and the people we deal with is very important to us. Much of the information that the University collects in order to provide the services that it does is "personal information". For details of how the University will use, disclose and protect your personal information please refer to http://global.curtin.edu.au/legal/privacy.cfm In order for the Animal Ethics Committee (AEC) to consider and approve an application to use animals for research or teaching, information is requested regarding the investigator(s), the project and its justification and methodology, especially addressing the welfare of the animals used. Additional information is required to ensure compliance with the current animal welfare legislation and the requirements of other statutory bodies. http://www.nhmrc.gov.au/publications/synopses/ea16syn.htm DESCRIPTION OF PROJECT 1. Project Title Project title. 1a. Project Title (Plain Language) Plain title. 2. Duration of Research Date of Commencement: 8/06/2012 Date of completion (for entire project): 26/6/2012 Please note: Approval is granted for a duration not exceeding 31 December for the year of approval, and is subject to renewal. You must apply to renew your application each year. Applications can only be renewed a maximum of three times. To continue beyond four years a new application must be submitted. 3. Is this a repetition of a previous experiment? Choose item Q3 j 4. Provide details of any external funding agency, industry partner or community group that support this project. Q4 5. Using simple non-technical language, state the aim(s) of the project and include the hypothesis being tested in Document1 2 of 20 this research. Q5 BENEFITS 6. Using simple non-technical language, state the significance, originality and/or the expected benefits of this project. Q6. 6a) What is the expected/potential value of the experiment. Tick the relevant category and provide further information in the box below. Choose an item. Q6a response Document1 3 of 20 INVESTIGATORS 7a) Project Supervisor (Only academic staff including adjunct members of staff can be named as the Project Supervisor. This is the person with whom the ultimate responsibility for the animal care and welfare lies; and whom the AEC will consider to be the contact person.) Name name . Staff Number Staff ID. School dept/school. Qualification/s Quals . Telephone telephone . Email email . 7b) Co Investigator(s) – (This is the person performing the animal procedures. If more than one Co investigator, copy this section and complete details for each Co investigator.) Name name . Staff Number Staff ID. School dept/school. Qualification/s Quals . Telephone telephone . Email email . 7c) Animal Carer (The animal carer is the person responsible for the day to day care and welfare of the animals. If more than one carer, copy this section and complete details for each person.) Name name . Staff Number Staff ID. School dept/school. Qualification/s Quals . Telephone telephone . Email email . 7d). Have the investigators and/or staff attended an animal user’s course? Choose item Q 7d) Document1 4 of 20 ANIMAL(S) No of Animals in First year Estimated No of Animals in 2nd yr Estimated No of Animals in 3rd yr Estimated No of Animals in 4th yr No of Animals for duration of project 8a) Insert details of the animal species to be used in the activity(ies) (See Appendix 1) Animal 1 ID Code Animal 1 SN Animal 1 0 0 0 0 0 Animal 2 ID Code Animal 2 SN Animal 2 0 0 0 0 0 Animal 3 ID Code Animal 3 SN Animal 3 0 0 0 0 0 Animal 4 ID Code Animal 4 SN Animal 4 0 0 0 0 0 Common Name ID Code Scientific Name Strain Name * If more than 4 species please attach additional information to this form 8b) Why is the requested species essential to the project? Click here to enter text. 8c) What is the source of the animal(s) to be used? (If from a non-approved source please attach a letter from the supplier advising their awareness and acceptance that the animals will be used for research). Click here to enter text. Document1 5 of 20 REPLACEMENT 9. Why are non-animal techniques (eg. computer simulation, cell culture) unsuitable for this project? NB: When appropriate, consideration should be given to using videotapes or other alternatives that do not use animals Click here to enter text. REDUCTION 10a) Describe the ways that you propose to minimise the number of animals. You must justify why you require the number of animals for this experiment. Click here to enter text. 10b) Have you consulted a statistician to determine the numbers of animals required for this project? Choose an item. Click here to enter text. 10c) Have the animals you intend to use been subject to any previous scientific experimentation or teaching activity? Choose an item. Click here to enter text. Document1 6 of 20 REFINEMENT 11a) Who will monitor the animals? (i) during weekdays? Click here to enter text. (ii) after hours, including weekends and public holidays? Click here to enter text. 11b) How will the animals be monitored on a routine day-to-day basis during the project? Give details of: (i) Method(s) to be used and specific signs you will monitor. (ii) Frequency of monitoring? Click here to enter text. Document1 7 of 20 11c) In relation to the description of the project, identify all aspects of this project that may adversely impact on the wellbeing of the animals using the table below. Anticipate and describe any potential adverse effects on the animals, and the steps you will take to avoid, minimise or manage these effects? Please attach copies of score sheets to be used. (Adverse Events Examples) Factor Y/N Potential adverse effects on How you are going to minimise these the animals potential adverse effects Click here to enter text. Anaesthesia with recovery ----- Click here to enter text. Click here to enter text. Anaesthesia without ----- Click here to enter text. recovery Click here to enter text. Surgical procedure(s) ----- Click here to enter text. Use of neuromuscular blockers Techniques used to administer substances (eg. Injection, gavage, intratracheal) Substances administered Blood / body fluid collection Antigen & adjuvant administration Infection with microbial agents, parasites etc Chronic instrumentation (eg. electrodes, catheters, transmitters etc) Diet / water modification ----- Click here to enter text. Click here to enter text. ----- Click here to enter text. Click here to enter text. --------- Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. ----- Click here to enter text. Click here to enter text. ----- Click here to enter text. Click here to enter text. ----- Click here to enter text. Click here to enter text. ----- Click here to enter text. Click here to enter text. Induction of tumours ----- Click here to enter text. Click here to enter text. Restraint ----- Click here to enter text. Click here to enter text. Transport ----- Click here to enter text. Click here to enter text. Housing ----- Click here to enter text. Click here to enter text. Individual housing ----- Click here to enter text. Click here to enter text. Housing and/or experimental environment Effect of genetic modification Handling ----- Click here to enter text. Click here to enter text. ----- Click here to enter text. Click here to enter text. ----- Click here to enter text. Click here to enter text. Capture of free-living (including feral) animals Behaviour observations ----- Click here to enter text. Click here to enter text. ----- Click here to enter text. Click here to enter text. Euthanasia ----- Click here to enter text. Click here to enter text. Other. ----- Click here to enter text. Click here to enter text. Document1 8 of 20 ANALGESICS 12a) Are analgesics to be administered to the animals in this activity? Choose an item. Click here to enter text. 12b) Give generic names and dose, route of administration, and duration, of all analgesic drugs to be used. (refer to Standard Operating Procedures http://research.curtin.edu.au/guides/facility.cfm ). Click here to enter text. BLOCKING AGENTS/ ANAESTHETICS/SEDATIVES 13a) Are neuromuscular blocking agents/anaesthetics/sedatives to be administered to the animals in this activity? Choose an item. Click here to enter text. 13b) Give generic names and dose, route of administration, and duration, of all blocking agents/ anaesthetics/sedatives drugs to be used. (refer to Standard Operating Procedures http://research.curtin.edu.au/guides/facility.cfm ). Click here to enter text. 13c) If the animals are to be anaesthetised for surgical or non-surgical procedures, will these animals recover? Choose an item. Click here to enter text. Document1 9 of 20 13d) Indicate which method(s) will be adopted to ensure the anaesthesia is adequate: Anaesthesia without neuromuscular paralysis (i) Small Animals (eg. rodents/rabbits) Pulse steady No hyper/hypoventilation No withdrawal reflex on painful stimulus such as pinching skin on leg or foot Anaesthesia with neuromuscular paralysis Electrical Stimulation Pulse steady Blood pressure steady (ii) Fish Response to stimuli Normal opercular rates (iii) Large Animals (eg sheep) Eye Position Palpebral Reflex No hyper/hypoventilation EXPERIMENTAL DESIGN (Techniques and Procedures) 14a) Please provide a detailed description of the methods and design of your experiment. Provide a sequence of all events and a step by step outline of what will happen to each animal from the beginning to the end of the experiment. Please also include a flow chart, diagram or sequence of events table illustrating the timelines for the procedures. Where appropriate you may refer to an attachment or a Curtin University Animal Ethics Committee approved Standard Operating Procedure. http://research.curtin.edu.au/guides/facility.cfm). Click here to enter text. Document1 10 of 20 ACTIVITY (please indicate the type of activity being conducted in the study) Control animal only Observation study only Basic animal handling study only Dissection study only Surgical study under GA – recovery Surgical study under GA – nonrecovery Surgical study-conscious animal Toxicological study under GA - recovery Toxicological study under GA non-recovery Toxicological study-conscious animal Other study under GA - recovery Other study under GA – non-recovery PROCEDURE (please indicate the procedures to be conducted) Use of anaesthetic Use of analgesia (pre or post GA, LA) Use of antibiotics (pre or post GA, LA) Use of tranquillising agents Ascites method of monoclonal antibody production Implanted devices Digit removal-conscious animal Organ and tissue transplantation Electro-immobilisation Animal model of disease Modifying animal behaviour Induction of tumours Lesions of the CNS Withholding food and water Research involving pain mechanisms or relief of pain Neuromuscular paralysis Cloning of animals Genetic modification of animals Repeated use of animals Document1 11 of 20 14b) Identify any novel or unusual procedures. Include suitable references to published literature, where appropriate. (not already indicated in 14a) Click here to enter text. 14c) Describe the housing and husbandry requirements: Click here to enter text. Caging or housing Click here to enter text. Maximum and minimum number of animals per cage/pen Click here to enter text. Environmental enrichment: Click here to enter text. Diet: Click here to enter text. Special care: 14d) Categorise the proposed techniques and procedures in accordance with the ‘Categorisation of animal experimentation’ procedures (See Appendix 2). Provide relevant category code(s). Category code Choose Category Category code Choose Category Category code Choose Category 14e) Of the procedures and techniques to be used on the animals (as listed in question 14a) please provide details of who will be conducting each technique/procedure. Person conducting the Competency Number or Technique or Procedure Office Use Only technique or procedure other form of reference Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. Document1 12 of 20 ANIMAL WELFARE ISSUES 15a) Is the transporting of animals required? (including delivery to site). Please include details of the supplier and or person conducting the delivery. Yes (How will any stress to the animal(s), caused by the transportation, be minimised and treated?) No Click here to enter text. 15b) Where will the animal(s) be housed during the project? Available facilities are: Animal Facility (Building 300) Bentley Campus Curtin Aquatic Research Laboratory (CARL) Building 610 (Tech Park) Bentley Animal Holding Facilities Dept of Environmental and Aquatic Sciences Other (please specify): Click here to enter text. 15c) Have you consulted with the appropriate Animal Facility Manager (of the facility indicated in 15b) that space will be available during your anticipated trial period? Choose an item. Click here to enter text. DISPOSAL OF ANIMALS/HUMANE KILLING 16a) What is the fate of the animals at the end of the experiment? Click here to enter text. 16b) How will animals be humanely killed or disposed of at the end of the experiment or in the event of adverse effects (refer to Standard Operating Procedures http://research.curtin.edu.au/guides/facility.cfm ). Click here to enter text. 16c) What provisions are there for the disposal of carcases (if required). Please note: This must comply with Section 4.8.1 of the Australian code of practice for the care and Document1 13 of 20 use of animals for scientific purposes 7th Edition. Click here to enter text. 16d) Have you made provision for tissue sharing with other investigators? Please provide details. Click here to enter text. RISK MANANGEMENT 17. Does this research/teaching activity involve any of the following: 1 Identifiable health risk to animal(s) 2 Identifiable health risk to staff 3 Use of radioactive isotopes 4 Use of materials and/or procedures that requires approval from the Institutional Biosafety Committee (IBC) (http://edusafe.edu.au/curtin/biosafety/index.html) 5 Intellectual Property implications 6 Production of commercial products/services Choose item Choose item Choose item Choose item Choose item Choose item Provide additional details below for any items given a YES response including how any risks will be minimised. Attach relevant notification of approvals from or submission of applications to the University's and the Institutional Biosafety Committee (IBC) and/or Radiation Safety Committee. Click here to enter text. Document1 14 of 20 REQUIRED PERMIT(S) 18. Provide details and attach a copy of the permit(s) required. Examples of permits include: DEC licence Exemption from Fish Resources Management Act Licence issued by the Fisheries WA DAFF (canetoads) Click here to enter text. OTHER ETHICAL CONSIDERATIONS eg conflicts of interest. Click here to enter text. Document1 15 of 20 GENETICALLY MODIFIED ORGANISMS The Gene Technology Act 2000 imposes various regulatory and licensing requirements on Curtin University when it engages in activities involving Genetically Modified Organisms (GMO). The University is committed to complying with these requirements and requires all researchers/teachers operating on premises under Curtin’s jurisdiction to complete a GMO Compliance Declaration whether or not GMO are to be used in any research/teaching using animals. This requirement also extends to research/teaching conducted on any of Curtin’s premises or facilities by or on behalf of an external organization. Researchers/teachers using GMO must consult the Biosafety Committee to determine the requirements and licence(s) required. The Gene Technology Act 2000 defines (in part) genetically modified organisms as: (i) an organism that has been modified by gene technology, or (ii) an organism that has inherited particular traits or properties from an organism (the initial organism) wherein the traits or properties occurred because of gene technology, or (iii) anything declared by the regulations to constitute a genetically modified organism, or (iv) anything declared by the regulations to belong to a class of organisms to be genetically modified organism, (v) but excluding an organism declared by the regulations not to be a genetically modified organism or belonging to a class of organisms not to be genetically modified organisms. By signing the GMO Compliance Declaration the researcher/teacher understands the GMO research cover any experiment/procedure/protocol conducted in a field, laboratory, glasshouse, aquarium as a trial, investigation, demonstration or evaluation involving plant, animal or microbial GMO materials. GMO Compliance Declaration I hereby certify that the research proposed and described in this application does [ ] or does not [ ] involve the use of GMO as defined above. I also understand that penalties defined under the Gene Technology Act 2000 may be imposed upon a person providing misleading or inaccurate information. Signed Signature . Print Name name Document1 Date enterdate. 16 of 20 Declaration: I declare that information in this proposal is correct, accurately represents the intended research, and that the research will be performed in accordance with this proposal. I am also aware of my responsibilities as set out in the current WA legislation and in the Australian Code of Practice for the Care and Use of Animals for Scientific Purposes (7th edition). Chief Investigator Name name Signature Signature . Date enterdate. Signature Signature . Date enterdate. Signature Signature . Date enterdate. Signature Signature . Date enterdate. Signature Signature . Date enterdate. Signature Signature . Date enterdate. Signature Signature . Date enterdate. Co-Investigator/s Name Name Name name name name Animal Carer Name Name Statistician Name Name Head of Enrolling Area Name name Office Use Only Application considered by AEC Signed Chairperson: Print Name: Date of Meeting: Document1 17 of 20 APPENDIX 1 ANIMAL SPECIES LISTING Domestic Species 010 020 Cattle Pigs 030 040 Sheep Goats 050 060 Horse Domestic poultry 070 080 Cats Dogs 090 Others Laboratory Animals Rats (Rattus norvegicus) 100 Outbred (indicate strain - Sprague Dawley, Wistar, etc) 120 Inbred (indicate strain) 140 Mutant (indicate strain) Mice (Mus musculus) 200 Outbred (indicate strain - ARC, Swiss, etc) 220 Inbred (indicate strain - BALB/c, etc 240 Congenic (indicate strain) 260 Mutant (indicate strain) 280 Recombinant (indicate strain) Guinea Pig (Cavea porcellus) 300 Outbred (indicate strain - Hartley albino, etc) 320 Inbred (indicate strain) Rabbit (Orctolagus cuniculus) 400 Dutch belted 420 NZ white 440 Other - please specify Australian Native Mammals Marsupials Macropods 500 Tammar (Macropus eugenii) 501 Quokka (M. brachyuris) 502 Bennetts Wallaby (M.rufogriseus) 503 Eastern Grey Kangaroo (M.giganteus) 505 Other Marsupial Mice 510 Kowari (Dasyuroides byrnei) 511 Dunnart (Sminthopsis - indicate species) 512 Other Native Cats 520 Eastern native cat (Dasyurus viverrinus) 521 Western native cat (D. geoffroii) 522 Other Bandicoots 630 Long nosed (Perameles nasuta) 631 Short nosed (Isoodon macrourus) 632 Other Koala 640 Phascolarctos sp Document1 18 of 20 Possums 650 Brush tailed (Trichosurus vulpecula) 651 Ringtailed (Pseudocheirus sp.) 652 Other 660 Dingo (Canis familiaris) 661 Native hopping mice (indicate species - Notomys alexis, etc) 662 Other Monotremes 670 Platypus (Ornithorhynchus anatinus) 671 Echidna (Tachyglossus aculeatus) Primates Macaques 700 Macaca fascicularis 701 M.nemestina 702 M.mulatta 703 Other Baboon 705 Papio hamadryas Marmoset 710 Callithrix sp; Saguinus sp. (indicate which) Other Primates 720 Indicate species Other Mammals 750 Indicate species Other Species 800 Fish (specify) 810 Amphibia (specify) Document1 820 Reptiles (specify) 840 Invertebrates 830 Birds - non domestic (specify) (specify) 19 of 20 3. APPENDIX 2 CLASSIFICATION OF PROJECT (please circle appropriate number(s)) Category 1: 1.1 No experimentation of living animals (ie animals are killed painlessly for biochemical analysis, or in vitro, cell, tissue or organ studies). 1.2 Experiments under anaesthesia, without recovery (ie animals are fully anaesthetised for the duration of the experiment, and are killed at its conclusion without recovery from anaesthesia). Category 2: 2.1 No anaesthesia, minor procedures used (eg injections, blood sampling, antibody raising, minor dietary manipulations). Category 3: Experiments or surgery under anaesthesia, with subsequent recovery of the animal. Category 4: Category 5: Category 6: Document1 3.1 Minor post-operative sequelae (eg following biopsies or cannulations). 3.2 Significant post-operative sequelae. 4.1 Studies on the biology of pain or of the responses to physical stresses (eg heat, cold, burning, ionising radiation). 4.2 Studies on unanaesthetised animals of the toxic actions of drugs or other chemical agents or of infectious agents. 4.3 Studies on unanaesthetised animals in which neuromuscular blocking agents are used. 4.4 Studies involving experimental induction of abnormal foetal growth. 4.5 Continuing or recurrent experimentation on individual animals that lasts more than three months. 4.6 Experiments involving the restriction of food or water intake, or other major dietary intervention. 4.7 Studies on mutant strains of animals prone to serious disease (eg stroke-prone rats). 4.8 Laboratory studies designed to produce substantial and overt changes in behaviour by physical or chemical means. 5.1 Experiments involving collaboration with commercial interests. 5.2 Experiments involving collaboration with overseas laboratories. 6.1 Other experimentation not covered above - please specify. 20 of 20