ANIMAL USE PROTOCOL
UNIVERSITY OF MASSACHUSETTS BOSTON
INSTITUTIONAL ANIMAL CARE AND USE COMMITTEE
This form must be completed for New, 3-Year Rewrite or
Approved
Protocols
having
significant
revisions/modifications including changing the species of
animals, changing procedures involving pain or stress,
using hazardous substances, or other types of significant
changes as may be determined by the Institutional Animal
Care and Use Committee (IACUC).
For IACUC Use Only
Date Submitted: ____________
Protocol Number: __________
Date Approved: ____________
The IACUC at the University of Massachusetts Boston (UMB), in
compliance with Federal Regulations and Guidelines, requires
this application to be completed and approved, in writing, prior
to initiating any animal activities involving the teaching, testing
or research use of animals. Changes in personnel or nonsignificant changes in procedures, such as equivalent methods, can be submitted directly
to the Chairman of the IACUC, who is authorized to approve such changes upon
verification of training for personnel and equivalency of methods. This application must
be completed for activities performed on UMB premises, at off-site facilities, or under field
conditions. The responsibility for completing this form and securing approval rests
entirely with the Principal Investigator (PI) named in this document.
Type of Application: [ ] New Submission [
PHS Policy) [ ] Revision/Modification
] Three Year Rewrite (Required by
General Information
Title Proposal:
_____________________________________________________________________
Name of Principal Investigator (PI):_________________________________________
(Note: If graduate student, a PI of standing with the IACUC must also be listed)
Qualifications & Training (Degree, years of experience in working with animals, etc.):
______________________________________________________________________
Department: ________________________
Telephone:
____________________
Emergency Telephone: ___________________________________________________
Source of Funding: ____________________
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Funding Period: ___________________
UMB Training Record:
CITIprogram.org date: _______________
LATAnet.com date: ________________
IACUC training date: ________________
Other Training (describe):___________
Animal Information
Species: _____________________________________________________________
Breed/Strain: __________________________________________________________
Vendor/Source: ________________________________________________________
(Note: Laboratory rodents are to be acquired from disease-free vendors/sources)
Weight Range: __________ Age Range: _________ Sex: Male [ ] Female [ ]
Maximum Daily Census: __________ Maximum Monthly Census: ___________
Total Annual Use: __________
To be completed by Animal Facility Manager: Is adequate caging available?
[ ] Yes
[ ] No
Is special caging required? Describe: ___________________________________________________
Animal Room Assignment: __________________________________________________________
Are there any animals to be used off site? [ ] Yes [ ] No If “Yes”, describe
facility, room or field circumstances:
______________________________________________________________________
______________________________________________________________________
Justification for Animal Activities
Justification for Species: _________________________________________________
Justification for Breed/Strain: ______________________________________________
Justification for Numbers of Animals: ________________________________________
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Rationale for procedures that may cause more than momentary pain or distress
(Category D) and why alternatives are not available: ____________________________
_____________________________________________________________________
Assurance that activities do not unnecessarily duplicate previous research
use of animals: _________________________________________________________
Literature searches: computer searches, references, conferences or consultations that
justify species, breed/strain, numbers of animals and rationale for Category D activities
should be performed. Computer searches should list by keywords, date and citation for
each justification. Justification is mandatory for Category D procedures. Face page
printouts of computer searches may be attached to this application:
Brief Abstract Description of Animal Activities and Objectives (500 words)
Detailed Description of Teaching, Testing or Research Design
In separate sections, below, describe groups of animals, acclimation of animals,
sequence of procedures from acquisition of animals to euthanasia (illustrated by
timeline), administration of drugs or test substances, surgery procedures, special
methods, endpoints, technical problems, adverse effects and euthanasia of animals.
Experimental Groups of Animals (how animals will be assigned for use):
Acclimation of Animals (methods to screen animals prior to use):
Sequence of Procedures and Timeline (describe all procedures from acquisition of
animals to euthanasia and provide a simple timeline to illustrate the description):
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Administration of Drugs, Chemicals or Test Substances: Describe the drug, chemical, or
test substance including - any method of preparation for a non-drug, route of
administration, dose, frequency of administration and duration of repeat administration
(days, weeks, etc.) for groups of animals:
The use of anesthetic agents for non-surgical procedures that might have associated
pain or stress must also be described. Information should include anesthetic agent(s),
route, dosage, signs of surgical plane and repeat dosage:
Surgery Procedures:
Survival [ ] Multiple-Survival [ ] Non-Survival [ ]
1. General description of surgery procedure (anatomical site, skin preparation,
tissues incised, closure, suture material):
2. Anesthetic(s) (agents, route, dosage, signs of surgical plane and repeat dosage):
3. What room will be used (Surgical Room in Animal Facility, or other?):_________
4. Recovery monitoring, signs and analgesic drugs including dose, route and repeat
dosage:
5. Will the animal be involved in any procedures after surgery? [
If Yes, describe procedures:
] Yes
[
] No
6. If the animal is to be euthanized following surgery, describe the method of
euthanasia:
Special Methods (describe any special methods for diet restriction, prolonged restraint,
tumor transplantation, administration of radioactive substances, carcinogens, mutagens
or hazardous substances and provide scientific justification for such methods. (Note:
UMB does not currently allow the use of infectious agents in animals.):
Diet restriction (food or water): [
] No [ ] Yes. If “Yes”, describe methods:
Feeding special diet (e.g., high v. low fat, etc.): [
diet(s) and methods:
] No [ ] Yes. If “Yes”, describe
Prolonged restraint (more than 30 minutes in a device): [
describe device and duration:
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] No [ ] Yes. If “Yes”,
Induced disease: [ ] No [ ] Yes. If “Yes”, describe disease being induced:
Animal behavior/exercise: [ ] No [
] Yes. If “Yes”, describe methods:
Radioactive substances: [
] Yes. If “Yes”, list substances:
] No [
Chemical carcinogens or mutagens: [
obtain MSDS information for your files:
Hazardous substances: [
information for your files:
] No [
] No [
] Yes. If “Yes”, list substances and
] Yes. If “Yes”, list substances and obtain MSDS
Will any animal activity images be created or used? Imaging of animal activities must
conform to the UMB Policy on Imaging for Research, Teaching and Testing.
Other special methods (describe in detail):
Endpoints, Technical Problems and Adverse Reactions (describe the criteria that
indicate objective has been attained, that a technical problem has occurred, or adverse
reaction occurred):
Euthanasia of Animals (describe agent, method of administration, method of verifying
death and list specific personnel authorized by PI to perform euthanasia. When
physical methods are used, the technique must be demonstrated to conform to the
AVMA Guidelines on Euthanasia. The method of euthanasia must also be described for
animals which become clinically affected from untoward causes, but must be humanely
euthanized and removed from research, teaching or testing. (Note: The Manager of
the Animal Facility is also authorized to perform euthanasia if the PI or personnel
authorized by the PI cannot be reached):
Agent(s) or methods used:
Method of administration:
Method of verifying death:
Personnel authorized to perform euthanasia by PI (list):
Personnel from Animal Facility who may perform euthanasia in an emergency (list):
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Personnel Authorized by PI to Participate in Animal Activities
1. Name:___________________________________________________________
Activity (describe):__________________________________________________
Qualifications( research experience):
____________________________________________________
CITIprogram.org date: _______________ LATAnet.com date: _______________
Read protocol(s) date: _______________
2. Name:___________________________________________________________
Activity (describe):__________________________________________________
Qualifications: ____________________________________________________
CITIprogram.org date: _______________ LATAnet.com date: _______________
Read protocol(s) date: _______________
3. Name: __________________________________________________________
Activity (describe):_________________________________________________
Qualifications: ____________________________________________________
CITIprogram.org date: _______________ LATAnet.com date: _______________
Read protocol(s) date: _______________
4. Name: __________________________________________________________
Activity (describe):_________________________________________________
Qualifications: ____________________________________________________
CITIprogram.org date: _______________ LATAnet.com date: _______________
Read protocol(s) date: _______________
5.
Name: __________________________________________________________
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Activity (describe):_________________________________________________
Qualifications: ____________________________________________________
CITIprogram.org date: _______________ LATAnet.com date: _______________
Read protocol(s) date: _______________
6. Name: __________________________________________________________
Activity (describe):_________________________________________________
Qualifications: ____________________________________________________
CITIprogram.org date: _______________ LATAnet.com date: _______________
Read protocol(s) date: _______________
PI Assurance Statement:
I have provided accurate information on my qualifications, description of all animal
activities, required documentation, personnel qualifications and training and other
documentation related to the animal activities in this application. I, and the assigned
personnel listed in this application, will work with the IACUC and UMB Animal Care Staff
to ensure that all animal activities, described herein, will be performed in accordance
with UMB Policies and Standard Operating Procedures. I understand that significant
changes in animal activities must be approved by the IACUC before any such changes
in animal activities can take place. I hereby acknowledge ownership of the animals to
be used and accept, in part, responsibility for UMB’s compliance with provisions of all
Federal regulations and guidelines, including the “Animal Welfare Act,” the PHS "Policy
on Humane Care and Use of Animals," and the ILAR “Guide for the Care and Use of
Laboratory Animals.”
I have read the above statement and understand my responsibility to provide assurance
of compliance with UMB standards.
Principal Investigator:
Signature:
______________________________
______________________________ (print name)
Date: ___________________________________
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Advisors Signature: (for student work)
Signature:
______________________________
______________________________ (print name)
Date: ___________________________________
Department Chair:
Signature:
______________________________
______________________________ (print name)
Date: ____________________________________
Certification of Animal Ownership:
Signature:
______________________________
______________________________ (print name)
Date: _____________________________________
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