Stevens Institute of Technology Institutional Animal Care and Use Committee
Animal Tissue Protocol Application
Instructions
1. Applicability.
This form is applicable to tissues from the following sources:
(a) Commercially available animal tissue.
(b) Animals from approved Animal Protocols.
(c) Animals that are to be slaughtered by a commercial supplier specifically for
your study. In this case, please attach a copy of the supplier’s Institutional
Animal Care and Use Committee (IACUC)-approved animal protocol to this
application. Approval of this Animal Tissue Protocol Application is contingent
upon review and approval of the supplier’s animal protocol by the Stevens
Institute of Technology (SIT) IACUC.
This form is not applicable if:
(a) You plan to obtain live animals in order to euthanize them for their tissues, in
which case you must submit an Animal Protocol Application and receive approval
for the protocol from the SIT IACUC.
(b) You plan to obtain commercially available preserved or purified tissues, histological
fixed samples, sera or antibodies, in which case SIT IACUC approval is not required.
2. Please provide all required information. Not completing this form as required
may delay the review of your application. For assistance in completing this form,
contact Justin Samolewicz in the IACUC office at 201- 216-8909 or
justin.samolewicz@stevens.edu.
3. Submit the completed and signed form to Justin Samolewicz:
justin.samolewicz@stevens.edu or Office of Sponsored Programs, Howe Center, 9th
Floor. If submitting the signed form in hard copy, please also submit an unsigned version
via email.
STEVENS INSTITUTE OF TECHNOLOGY
INSTITUTIONAL ANIMAL CARE AND USE COMMITTEE
Animal Tissue Protocol Application
Application
A.
B.
YES
NO Will the treatment (diet, biopsies, surgery, etc.) of any live animal be
altered specifically to obtain tissues for your research use?
YES
NO Will an animal be captured, trapped or euthanized specifically for your
research use?
If you answered YES to either question above, please complete the remainder of this form and have the
principal investigator (PI) of the appropriate Animal Protocol complete an Animal Protocol Amendment
Application. Submit both forms to the IACUC for approval.
If you answered NO to both questions above, please complete the remainder of this form and submit it to
the IACUC for approval.
1 Principal investigator:
Name:
Academic Title:
PhD
MD
Other ___ Phone No:
Mobile Phone No:
Department:
Fax:
Pager Number:
Email:
2 Project Information:
Title:
Source of funding:
Grant number:
Proposed length of use:
Starting Date:
Ending Date:
3 Tissue Sample Information
A.
YES
NO Is the tissue coming from an IACUC approved Animal Protocol that is
approved for tissue harvesting/sharing and does not require any modification?
?
If Yes:
Name of PI______________
Protocol # _______________
If No, check and complete one of the two following sections:
Request has been made for a principal investigator to submit an Animal Protocol Amendment
Application requesting permission for tissue sharing and/or for necessary protocol
modifications.
Name of PI_______________
Protocol # _______________
Tissue is sourced from a commercial vendor
Vendor name: _______________________________
Location: ___________________________________
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STEVENS INSTITUTE OF TECHNOLOGY
INSTITUTIONAL ANIMAL CARE AND USE COMMITTEE
B.
YES
NO Will tissue to be obtained contain radioactive, hazardous, infectious, or
recombinant DNA material?
If Yes, contact the Institutional Biosafety Committee (IBC) to obtain approval to receive and
work with the tissue. Attach the IBC approval letter, with safety guidelines, to this form.
4 Type of animal tissue requested:
Animal Species
Tissue Type
Quantity & Frequency
5 Location of use:
Building:
Room Number:
Name of contact person:
Phone number:
6 What is the goal/specific aim of this project? Describe the relevance of the study to
advancing scientific knowledge and/or the benefits of the study to human and/or animal health.
Jargon should be avoided. All terms, including acronyms, must be explained.
7 Provide a description of how the tissues are to be used:
8 Disposition of the animal tissue/cadaver after use. Please describe how the tissue/
cadaver will be disposed of after use, and by whom:
9 Declarations:
Please check all applicable boxes below:
The information contained in this application for use of animal tissue/cadaver is accurate to the
best of my knowledge.
For work on this Animal Tissue Protocol, there will be no contact with live animals.
No animals will be euthanized specifically for this study.
I will not begin work on this project involving tissues prior to the receipt of IACUC approval.
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STEVENS INSTITUTE OF TECHNOLOGY
INSTITUTIONAL ANIMAL CARE AND USE COMMITTEE
I certify that all persons working on this project, including myself, will comply with all SIT rules and
regulations including those on occupational safety and health.
Signature of Principal Investigator
Date
Sponsor/Mentor Signature (IF APPLICABLE)
Date
Approval Signature (IACUC Chair or Co-chair)
Date
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