Renewal Date Addendum to Annual Review Form

Harvard Medical Area (HMA) Standing Committee on Animals – “Established in 1907”
180 Longwood Avenue, Suite 113 Boston, MA 02115 Tel: 617-432-3192 Fax: 617-432-3169
[email protected]
Fax Number:
Phone Number:
Protocol Number:
Date Approved:
Date Due:
Principal Investigator:
Title of Protocol:
Please complete the information requested below and email or fax this form to the ORSP.
A. What is the status of your animal protocol (circle one)?
If closed, please indicate closure date above, sign and date this form and return to this office immediately.
B. Indicate ‘APPROVAL DATE’ for any amendments approved since the last FULL IACUC Review:
If you intend to change the species, number of animals, and/or any activity related to this animal protocol, YOU MUST
submit a Protocol Amendment Form for review at the next meeting (
C. Where are your research animals housed?
D. Where are your animal procedures performed for this protocol? Bldg. ____________ Rm(s). ___________
E. List all current lab personnel, including new research fellows, who are working with animals. Give their name, title,
phone/e-mail contact information, and experience/training for each species related to this animal protocol. Use the 3rd
page of this form for that information. Please see attached Memorandum for important information, including
training requirements. ONLY those listed will be considered ACTIVE on the protocol. Others will be removed from the
protocol. Lab Staff must sign off on the last page of this form.
F. Are you using the ascites method of monoclonal antibody production? YES
(If YES, please request and fill out an Exemption Form for the ascites method for review at the next meeting. More
information is provided in the attached Memorandum.)
G. Describe the funding for your study: Funding Agency
Grant Title
Grant Number
H. USDA-covered species
Specify species:
If you have approval for and are using USDA-COVERED SPECIES (any animals other than mice or rats bred for research,
aquatics, or birds), you must state the number of animals used in the past year, any problems or adverse events that may
have occurred with each species, and justify the continuation of any IACUC approved exemptions from the AWA:
i. Describe the use of your animals over the course of the past year, including the number of animals
HMA IACUC Annual Renewal Form
Revised November 15 2012
Page 1 of 4
ii. Describe any adverse events in the past year:
iii. If you currently hold an exemption from Animal Welfare Act (AWA) standards such as for water
scheduling, food restriction for behavioral testing, use of non-pharmaceutical grade substances, or
non-social housing, please be advised that the exemption must be reviewed annually. If so, please
1. Briefly describe the Exemption you hold (either contained within your protocol itself, or on a
separate Exemption form) and whether you intend to continue its use:
2. Note any changes to the existing justification, if any:
If you have approval for and are using FISH and/or FROGS, you must describe the number of animals used in the past year:
a. FISH: ____
b. FROGS: ____
Sign below and return this form to the Office for Research Subject Protection by email or fax.
PI Signature:
Reviewed by IACUC Member: ___________ Date: ________
Based upon the information given above, this protocol has been found acceptable for renewal for ONE YEAR.
Signature of IACUC Chairman:
Renewal Date
HMA IACUC Annual Renewal Form
Revised November 15 2012
Page 2 of 4
Addendum to Annual Review Form (all current personnel)
Principal Investigator: _________________________________ Protocol #: ___________________
Protocol Title: ____________________________________________________________________
Department & Institution:
The investigator and research staff assigned to this protocol are required to sign this form, thus certifying that they: (1) have read the protocol; (2) are familiar with all of its
requirements, and the requirements of all rules, regulations and policies governing the care and use of animals relating to their activities; (3) have had the opportunity to ask
questions about it; (4) understand that all animal experimentation not described in the protocol is prohibited in the absence of an approved amendment.
NB: Clinical staff members that do not have substantial, direct, intellectual contributions to the work do not need to sign below.
Name / Degree
Position on Protocol
Experience/training with species and with animal
procedures specific to this protocol
Phone & email
AALAS Learning
Library Training
Update Departed Personnel: ____________________________________________________________________________________
HMA IACUC Annual Renewal Form
Page 3 of 4
Revised November 15 2012
Harvard Medical Area (HMA) Standing Committee on Animals – “Established in 1907”
180 Longwood Avenue, Suite 113
Tel: 617-432-3192
Fax: 617-432-3169
[email protected]
All Harvard Medical Area Animal Protocol Investigators
Attached is an Annual Review Form for your currently approved Animal Protocol. If you intend to keep this protocol
active, please complete, sign, and return the Annual Review Form electronically or via fax before the due date
noted (usually six weeks before the expiration date of your protocol). Amendments to protocols must be submitted
on an Amendment Form obtained from the IACUC website:
If a response is not received by the expiration date, your protocol will be automatically inactivated in the animal
database. You will be unable to order animals and existing animals will be transferred to the HCCM holding protocol
(receivership). It is unlawful to perform any experimental procedures on animals while a protocol is inactive.
Personnel Training: All lab members must take required AALAS Learning Library Online Courses. Please see the
attached FAQ with further instructions.
Ascites Production: Exemptions for ascites production must be renewed annually. If this protocol includes the
ascites method, submit an Exemption Form with this renewal.
HMA IACUC Annual Renewal Form
Revised November 15 2012
Page 4 of 4
Related flashcards

23 Cards

Create flashcards