Application for a Protocol: version 9/15/14-ckk
APPLICATION FOR A PROTOCOL FOR USE OF ANIMALS IN RESEARCH OR TEACHING
IUPUI School of Science Institutional Animal Care and Use Committee (IACUC)
[Attach additional information for each question on a separate document if needed]
{Refer to instruction packet for additional explanations of each section and application procedures}
Principal Investigator
Rank
Department
Campus Address
Email:
Title of Project (and Course number if applicable):
Telephone
Anticipated Start date (must be after IACUC approval):
Anticipated completion date (three year limit) :
Total number of requested animals listed by Species & Strains (common name & genus):
Funding for this project:
External agency and title:
Internal source and title:
Check all that apply to this project:
Animals from noncommercial sources
Immunizations
Tumor growth (including hybridomas)
Chemical / biological hazards
Exposure to adverse stimuli
Survival surgery
Project is for the use of animals in Teaching
Unrelieved Pain and/or distress
Prolonged restraint
Food, nutrient, or water deprivation
Radioactivity in vivo
Nonstandard husbandry
Multiple surgeries
University policy on Anesthetic Gas Safety requires researchers and staff to complete an on-line training course before using anesthetic gases
http://www.ehs.iupui.edu/AnesGasSafety/home.asp
By signing this form, I assure that discomfort and injury to animals will be limited to that which is unavoidable in the conduct of
valid scientific research. I have consulted with a veterinarian regarding potentially painful procedures. I agree to comply with all
applicable state and federal laws governing animal welfare, funding, and the instructions of the IACUC. I also agree not to initiate
or significantly change procedures using live animals without review and approval by the IACUC.
Principal Investigator
Date
OFFICE USE ONLY: PROTOCOL #
APPROVED
DISAPPROVED
Origination date is IACUC signature date (Protocol expires three years after last IACUC signature date)
SOS IACUC Signature
Date
Attending Veterinarian Signature
Date
SOM IACUC Signature
Date
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Application for a Protocol: version 9/15/14-ckk
REFER TO THE INSTRUCTIONS FOR ASSISTANCE IN COMPLETING ITEMS 1-7
1.
Lay-oriented summary of purpose: State the short-term aims, long-term goal, and significance of
this project in lay terms (understandable by a non-scientist High School graduate).
2.
Consideration of rationale, justification, and alternatives: Provide rationale for the involvement
of animals in this project. Include:
a) Why the use of animals is necessary
b) Why they cannot be replaced by non-animal alternatives
c)
Why procedures causing more than momentary pain and distress are necessary
Justify the appropriateness of the species and strain to be used. If the study involves transgenic,
knockout, or other genetically altered animals, approval of the appropriate committee is required
prior to IACUC approval.
Justify the number of animals to be used, e.g. based on statistical power analysis, existing literature,
previous findings, etc.
Describe the computer searches used in the deliberation concerning animal use and methods.
Include:
1. The database(s) searched:
2. Years covered by each search performed (minimum of ten years):
3. Keywords used to address alternatives to animal use ("alternatives" must be a keyword):
4. Keywords used to address alternatives to animal procedures causing more than momentary pain
and distress ("alternatives" must be a keyword):
5. Date computer search was performed (mm/dd/yy):
If alternatives were found, please justify why these alternatives were not selected.
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Application for a Protocol: version 9/15/14-ckk
3.
Assurance that the research is not unnecessarily duplicative: Provide a explanation assuring
that the project does not unnecessarily duplicate previous research.
Describe the database search used in your deliberation.
Include:
a) The database(s) searched:
b) Years covered by this search (minimum of ten years):
c) Keywords used:
d) Date computer search was performed (mm/dd/yy):
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Application for a Protocol: version 9/15/14-ckk
4.
Personnel: All personnel with animal contact must complete the SARC animal care training.
* PI responsible for animal use, tracking the number used, personnel training, and required record keeping.
Title
* Principal
Investigator
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Name
Role in project
Qualifications to perform role
Application for a Protocol: version 9/15/14-ckk
5.
Animal Husbandry:
Source of animals:
Commercial vendor
Other external source (including other IU facilities). (Specify: ______________ )
*Other IUPUI School of Science Protocol(s) #: ________________
*If the source of animals is another protocol, describe the time points and circumstances of the
listed Protocols when the animals will be transferred. Provide a specific statement assuring that
multiple surgeries on the same animal will not be performed unless approved by the IACUC and
that protocols supplying animals have specific approval by the IACUC on file for transfers to
take place (section six in an approved Protocol for Use of Animals in Research or Teaching):
Total number of animals to be used in this project:__________
Estimated average population housed at one time:
Estimated average number of animals housed per cage:
Special or nonstandard care requirements (see instructions for examples) [single housing should be
justified]:
Will the animals be housed 12 hours or longer outside the main facility? ____yes
______no
If yes, state how many animals will be involved, where they will be kept and for how long, and
why housing outside the main facility is necessary.
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Application for a Protocol: version 9/15/14-ckk
6.
Disposition and Euthanasia:
What will be the disposition of the animals after completion of the project? (Check all that apply)
Euthanasia
Shipment outside of IUPUI School of Science
Name and affiliation of recipient:_______________________________________
________________________________________
Transfer to protocol # ___________________
Describe the time points and circumstances when the animals will be transferred.
Method of euthanasia:
Lethal injection (specify drug, dose, and route)
Inhalation of anesthetic gases (training required: pg 1), Specify type:
Inhalation of CO2 (rodents, terrestrial amphibians, birds)
Other (explain and justify)
Identify physical means to assure death after chemical euthanasia: ___________________
Will animals suffering severe pain or distress be euthanized?  Yes /  No
If responding "No", you must complete Item seven, section five (see instructions)
What criteria will be used to assess pain or distress?
If euthanasia is an integral part of tissue procurement (e.g., perfusion), refer to instructions and
describe methods:
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Application for a Protocol: version 9/15/14-ckk
7.
Project Description: State your hypothesis and a brief methodology. Provide a detailed description of the
use of animals in this project. The instructions have a nonexclusive outline of items to include.
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