Animal Care/Use Program
AMENDMENT FORM
ORC Use Only:
Protocol #: __ __ - __ __ __
Amendment Approval:
Form completion instructions: To populate a box, 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.
Protocol Title: Click here to enter text.
Principal Investigator: Name: Click here to enter text. Department: Click here to enter text.
This application requests amendment of the animal use protocol for the above project by changes in (check
all area/s which apply):
☐ Animal subjects: Check applicable option(s) below:
☐ Species ☐ Number
Complete 1 – Change in Species or Animal Numbers
☐ Activity location:
Check applicable option(s) below:
☐ Housing ☐ Non-surgical procedure ☐ Survival surgery ☐ Non-survival surgery
Complete 2 – Change in Location of Animal Activity
☐ Non-surgical procedure or treatment Complete 3 – Change in Non-surgical procedure AND 5 - Purpose
and scientific benefit of procedures to be added.
☐ Surgery or intra-operative procedure: Check applicable option(s) below:
☐ Non-survival
☐ Survival
☐ Multiple survival
Complete 4- Change in Surgical Procedure AND 5 - Purpose and scientific benefit of procedures to be
added
☐ Post-surgical or post-procedure care and monitoring or humane endpoints
Complete 6 - Change in animal care and monitoring or humane endpoints
☐ Use of hazardous agents: Check applicable option(s) below:
☐ Biological
☐ Chemical
☐ Radiological ☐ Laser
Complete 7 - Change in use of hazardous agents administered to animals
☐ Method of euthanasia: Complete 8 ☐ Personnel: Check applicable option(s) below. NOTE: Relevant training is mandatory for all
professional & technical personnel involved with animal research protocol, including students.
☐ Addition or deletion of individuals with a significant role in the project such as the
administration of anesthesia, performing surgery, giving injections, etc.
☐ Change in project roles for existing personnel
Complete 9 - Change in personnel or personnel roles.
☐ Other significant change in activity: Complete 10 - Other change in animal use activity.
1. Change in Species or Animal Numbers
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Delete
Species
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text.
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text.
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text.
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Number approved
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Number to be added
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Justification for change in species:
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Justification for additional animals, including experimental groups and the basis for group sizes:
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2. Change in location for approved animal activity
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Delete
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Building
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enter text.
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enter text.
Room
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to enter
text.
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to enter
text.
Activity
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Species involved
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Reason for the change in location, and identification of location, activity, or species not specified above:
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3. Change in non-surgical procedure. Check applicable option(s) below. NOTE: AV review is required
for additions that have potential for more than slight or momentary pain or distress.
☐ Add procedures described in detail below:
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☐ Delete previously approved procedures specified below:
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For additions, complete the following checkboxes and item #5 below:
Pain or distress category will be:
☐ No pain or distress
☐ Momentary or slight pain or distress
☐ Pain or distress relieved by anesthesia, analgesia, or sedation
☐ Pain or distress that will not be relieved by drugs
Post procedure monitoring will be:
☐ As described in approved protocol
☐ As described in # 6 below
Humane endpoints will be:
☐ As described in approved protocol
IACUC Amendment Form – August 2015
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☐ As described in # 6 below
4. Change in surgical procedure.
☐ Add non-survival surgery procedures: Add description in box below:
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☐ Add survival surgery procedures described in detail below:
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☐ Delete previously approved survival or non-survival surgery procedures specified below:
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Justification for repeated survival surgery on individual animals, if multiple survival surgery is added:
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For additions, complete the following areas below and #5 below:
Pain or distress categories for added surgery: Check applicable option(s) below.
☐ Pain or distress relieved by anesthesia, analgesia, or sedation
☐ Pain or distress that will not be relieved by drugs
Post procedure monitoring will be:
☐ As described in approved protocol
☐ As described in # 6 below
Humane endpoints will be:
☐ As described in approved protocol
☐ As described in # 6 below
5. Purpose and scientific benefit of procedures to be added.
Specify the relationship of added procedures to the purpose of the study as described in the
approved protocol:
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State how the added procedures will contribute to the scientific benefit of the approved protocol:
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6. Change in animal care and monitoring or humane endpoints.
☐ Add post-procedure and/or post-surgical care and monitoring procedures described in detail below:
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☐ Delete previously approved care and monitoring procedures specified below, including reason for
deletion:
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For additions, summarize monitoring indices and humane endpoints below:

Monitoring during recovery from anesthesia (until sternal recumbancy):
Index
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Body temperature
Heart rate
Blood pressure
Respirations
Other (specify):
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IACUC Amendment Form – August 2015
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Observation frequency
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Monitoring to detect post-surgical or post-procedure pain or distress:
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Index
Body weight
Food consumption
Activity
Appearance
Behavior
Other: (specify)
Observation frequency
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Duration of monitoring
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Humane endpoints used to remove animals from study to avoid chronic pain or distress:
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Not eating > 48 hours
Weight loss > 20% of normal weight
Mutilation of operative site
Depression > 72 hours
Non-weight bearing > 72 hours
Infection not resolved with antimicrobial therapy
Moderate to severe clinical signs of pain and distress unalleviated by appropriate
analgesics
Other (specify): Click here to enter text.
7. Change in use of hazardous agents administered to animals.
Add hazardous agent use as described in detail below:
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Delete use of hazardous agents specified below:
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For additions, complete the following:
Nature of hazardous agents: Select all that apply:
☐ Biological (pathogens, human cells, tissues or fluids, tumor cells, non-replicating viruses,
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recombinant DNA)
Toxicological
Laser
Radiological (isotopes or ionizing radiation)
Carcinogenic
Agent identification:
Agent Name /
Description
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text.
Type of Agent
☐ Biological
Hazard
Dose /
Concentration
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enter text.
☐ Chemical
Hazard
☐ Radiation
Hazard
☐ Other
Specify:
IACUC Amendment Form – August 2015
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Route
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here to
enter
text.
Frequency of
Administration
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enter text.
Anticipated
Duration of
Effect
Method of
Waste
Disposal
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enter text.
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enter text.
Agent Name /
Description
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text.
Type of Agent
☐ Biological
Hazard
Dose /
Concentration
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enter text.
☐ Chemical
Hazard
Route
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here to
enter
text.
Frequency of
Administration
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enter text.
Anticipated
Duration of
Effect
Method of
Waste
Disposal
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enter text.
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enter text.
☐ Radiation
Hazard
☐ Other
Specify:
8. Change in method of euthanasia.
Describe method: Click here to enter text.
Scientific justification for use of the above method: Click here to enter text.
9. Change in personnel or personnel roles.
For addition of personnel, please fill in rows as indicated. To add rows…
Personnel to be Added
Techniques
FOR IACUC OFFICE ONLY
Select all that apply for this project/protocol.
Select all that apply for
this project/protocol.
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
☐ Temporary Personnel
☐ Other Specify:
Click here to enter text.
IACUC Amendment Form – August 2015
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(Continued)
☐ 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:
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CITI Training
Completed?
Vivarium
Orientation
Completed?
Enrolled in
Occ Health
Program?
☐ YES
☐ YES
☐ YES
Date:_________
Date:_______
Date:_____
☐ NO
☐ NO
☐ NO
For removal of personnel, provide full name and 800 # below:
First Name
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Last Name
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800 #
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For change in project role of personnel, complete the below table:
Change in animal handling role for existing personnel:
Name (First and Last)
New or additional animal
handling role in project
Click here to enter text.
☐ Principal Investigator
☐ Co-Investigator
☐ Animal Handler
☐ Animal Orderer
☐ Official Contact
☐ Emergency Contact
☐ Surgeon
☐ Temporary Personnel
☐ Other Specify:
Click here to enter text.
☐ Principal Investigator
Click here to enter text.
☐ Co-Investigator
☐ Animal Handler
☐ Animal Orderer
☐ Official Contact
☐ Emergency Contact
☐ Surgeon
☐ Temporary Personnel
☐ Other Specify:
Click here to enter text.
IACUC Amendment Form – August 2015
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New or additional technique(s)
NOTE: The AV reserves the right
to request training and
demonstration of proficiency of
personnel prior to use of new or
added techniques on live animals.
☐ 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
☐
☐
☐
☐
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
☐ Ear notch/ear tag
☐ Weighing /
measuring
☐ Cardiac puncture
☐ Cervical
dislocation w/
anesthesia
☐ CO2 euthanasia
☐ Decapitation w/
anesthesia
☐ Exsanguination
☐ Retro-orbital
injection
☐ Saphenous bleed
☐ Tall clip bleed
☐ Other Specify:
Click here to enter
text.
10. Other change in animal use activity.
Add activity described in detail below:
Click here to enter text.
Delete activity specified below:
Click here to enter text.
PI Assurance Statement:
I assure that the information contained on this form is accurate to the best of my knowledge. I affirm
that I will continue to uphold my responsibilities as Principal Investigator as detailed in the PI Assurance
Statement I signed upon the initial approval of this referenced protocol for the balance of the time the
IACUC has allotted for this study. I and all lab personnel listed on this protocol will continue to conform
to all applicable federal regulations and institutional policies regarding the care and use of animals on
this study.
_____________________________________________
PI Signature
________________
Date
Chair Approval and Signature – For Office Use Only:
______________________________________
___________________
Dr. Yvette Huet – Chair
Date
IACUC Amendment Form – August 2015
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