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.
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. The table will enlarge to the size you
. To ‘undo’ the check, click
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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
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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
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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)
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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).
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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
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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.
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10b)
Have you consulted a statistician to determine the numbers of animals required for this project?
Choose an item.
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10c)
Have the animals you intend to use been subject to any previous scientific experimentation or
teaching activity?
Choose an item.
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REFINEMENT
11a)
Who will monitor the animals?
(i)
during weekdays?
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(ii)
after hours, including weekends and public holidays?
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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?
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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
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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.
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-----
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---------
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-----
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-----
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-----
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-----
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Induction of tumours
-----
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Restraint
-----
Click here to enter text.
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Transport
-----
Click here to enter text.
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Housing
-----
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Individual housing
-----
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Housing and/or
experimental environment
Effect of genetic
modification
Handling
-----
Click here to enter text.
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-----
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-----
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Capture of free-living
(including feral) animals
Behaviour observations
-----
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-----
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Euthanasia
-----
Click here to enter text.
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Other.
-----
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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.
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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).
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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
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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
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Environmental enrichment:
Click here to enter text.
Diet:
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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
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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
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use of animals for scientific purposes 7th Edition.
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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
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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.
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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.
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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
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Date
enterdate.
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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:
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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
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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)
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820 Reptiles (specify) 840 Invertebrates
830 Birds - non domestic (specify)
(specify)
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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:
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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.
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