NUS Institutional Animal Care and Use Committee
T00/12
Date revised: May 2012
Form expiry date: 31 Dec 2012
Application to Use Animal Tissues
(from sources other than live animals specifically obtained for this purpose)
Instructions
1. This form is applicable for the use of tissues from the following sources :
(a). Commercially available animal cell lines.
(b). Euthanized animals from an approved protocol.
(c). Cadaver/Tissue from abattoir or purchased from the market.
(d). Cadaver collected from the field, e.g., road-kill.
2. This form is not applicable if:
(a). You plan to obtain live animals in order to euthanize them for the tissues.
(b). If animals are slaughtered by a commercial supplier specifically for your study.
These applications should be made using the form Application to Use Animals
for Research.
3. This form must be completed using MS word.
4. Please provide all the information required. Not completing the form as required
may delay the reviewing of your application. Please contact IACUC office 6516
2861 or email: dprnmya@nus.edu.sg if you need assistance in completing this form.
5. Please submit a soft copy to: dprnmya@nus.edu.sg.
Tissue Form
1
NUS Institutional Animal Care and Use Committee
T00/12
Date revised: May 2012
Form expiry date: 31 Dec 2012
Application to Use Animal Tissues
(from sources other than live animals specifically obtained for this purpose)
For IACUC Office Use Only
Ref./ Protocol No
Date received
Approval / Acceptance Date
IACUC Meeting
DR
Notification
T00/12
General Information
1
Project title:
2
Source of funding:
3
Grant number:
4
Proposed length of use:
Starting Date:
5
Ending Date:
Principal investigator:
Name:
Academic Title:
Department:
Phone No:
Mobile Phone No:
Fax:
Email:
NUS Staff Number:
6
Occupational Health and Safety
Under OSHE’s safety and health procedures, all research projects must undergo a risk
assessment to determine the appropriate medical surveillance, vaccinations and personnel
protective equipment (PPE) required for members involved in the project.
(a) Have you provided the details of the use of animal tissues for your in vitro work
to OSHE for Risk assessment (Section B of OSHE project risk assessment)?
Yes. OSHE Risk Assessment No:
No. Please submit. Please be reminded that OSHE risk assessment approval is required
before your work can commence.
N.A. Please explain:
(b) Does the in vitro work also involve the use of human cells / tissues?
No.
Yes. Please answer the following questions:
(i) Have you provided the details in your risk assessment?
Yes.
No. Please submit.
(ii) Have you obtained the approval from IRB?
Tissue Form
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NUS Institutional Animal Care and Use Committee
T00/12
Yes. IRB Ref No:
No. Please submit. Please be reminded that IRB approval is required before your
work can commence.
(c) Bio-safety level (BSL) of the project:
BSL1
7
BSL2
BSL3
Type of Application:
Use of commercial or established secondary animal cell lines for in vitro work only. Please
complete Part 1.
Use of animal tissues. Please complete Part 2.
Tissue Form
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NUS Institutional Animal Care and Use Committee
T00/12
Part 1
Use of Commercial or Established Secondary Animal Cell Lines
(for in vitro work only)
8
Type of cell line:
Name
Animal Species
Source
(Name and address of the supplier)
9
Location of use: Building:
Room Number:
10 Declaration:
I affirm the accuracy of the information provided in this form.
I will not begin work on the project prior to the approval of a risk assessment from OSHE.
I will not begin work on the project involving human cell lines prior to submission of eDeclaration to IRB.
The animal cell lines are for in vitro work only; at no time will live animals be used.
Signature:______________________
Date: __________________
Name of PI:
-- End of Part 1 --
Tissue Form
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NUS Institutional Animal Care and Use Committee
T00/12
Part 2
Use of Animal Tissues, Fluids and Cadavers
(for in vitro work only)
8
Type of animal tissue requested:
Animal Species
Tissue Type
Quantity & Frequency
Please describe how the tissue or cadavers are packed, transported to the location where it will
be used:
Packaging method:
Transportation (provide means and route) and safety procedures:
9
Source of animal tissue/cadaver:
(a) Commercial source / abattoir
Provide the name and address of the supplier:
(b) Dead animals collected from the field (e.g. from car accidents, etc).
Provide location and cause of animal death, if known:
(c) Euthanized animal from approved protocol. IACUC Protocol Number:
Is the approved protocol participating in tissue sharing. i.e, the principal investigator of this
protocol has provided the treatment information of the euthanized animals in the signed
Tissue Sharing form submitted to IACUC Office.
Yes. Approved protocol participating in tissue sharing.
No. Please request the principal investigator of this protocol to submit the Tissue
Sharing form.
N.A. Approved protocol from other institutions. Please submit Appendix 1c completed by
the principal investigator of this protocol.
(d) Non-euthanized or euthanized animals from the following sources:
Indicate the source of the animals :
Appendix 1a or 1b to be completed by the source
(e) Other sources. Please describe:
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NUS Institutional Animal Care and Use Committee
T00/12
10 Location of use:
Building:
Name of contact person:
Room Number:
Phone number:
11 Disposition of the animal tissue/cadaver after use. Please describe how the tissue/
cadaver will be disposed of after use, and by whom:
12 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 or explicitly explained (please define all acronyms).
13 Provide a description on how the tissues are used:
14 Declaration:
The information contained in this application for use of animal cadaver/tissue is accurate to
the best of my knowledge.
There will be no contact with live animals and no animals will be euthanized specifically for
this study.
I will not begin work on the project involving human tissues prior to the approval of IRB.
I certify that all persons working on this project, including myself, will comply with NUS
policies and procedures on occupational safety and health, which are administered by the
Office of Safety, Health and Environment (OSHE).
Signature:______________________
Date: __________________
Name of PI:
-- End of Part 2 --
Tissue Form
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NUS Institutional Animal Care and Use Committee
T00/12
Appendix 1 a
Tissue from Comparative Medicine, NUS
Comparative Medicine (CM) agrees to supply the following tissues to IACUC
protocol No:
Tissues from non-euthanized animals
I declare that the non-euthanized animals are maintained solely for tissue
supply and that these animals are healthy animals not exposed to any
experiments and thus free from the following:






Hazardous chemicals / biochemical
Radioactive materials
Infectious agents
Human blood, body fluids and cells
Other animal cells
Recombinant DNA.
I also declare that non-invasive and non-surgical procedures (pain category
C) are used in the collection of the tissues and that the NACLAR guidelines
are complied with in regard to the quantity and frequency of collection of the
tissues.
I further declare that euthanasia will be carried out once the animals
encounter unrelieved symptoms of pain and distress, in compliance with the
NACLAR guidelines.
Tissues from euthanized or deeply anaesthetized animals just prior to
euthanasia.
I declare that the animals are to be euthanized soon after tissue collection
under an approved protocol and that these are healthy animals not exposed
to any experiments and thus free from the following:






Hazardous chemicals / biochemical
Radioactive materials
Infectious agents
Human blood, body fluids and cells
Other animal cells
Recombinant DNA.
Signature:______________________
Date: __________________
Name:
Comparative Medicine
Tissue Form
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NUS Institutional Animal Care and Use Committee
T00/12
Appendix 1 b
Tissue form other sources
(Name of source) agrees to supply the following tissues to IACUC protocol
No:
Tissues from non-euthanized animals
I declare that the non-euthanized animals are maintained solely for tissue
supply and that these animals are healthy animals not exposed to any
experiments and thus free from the following:






Hazardous chemicals / biochemical
Radioactive materials
Infectious agents
Human blood, body fluids and cells
Other animal cells
Recombinant DNA.
I also declare that non-invasive and non-surgical procedures (pain category
C) are used in the collection of the tissues and that the NACLAR guidelines
are complied with in regard to the quantity and frequency of collection of the
tissues.
I further declare that euthanasia will be carried out once the animals
encounter unrelieved symptoms of pain and distress, in compliance with the
NACLAR guidelines.
Tissues from euthanized or deeply anaesthetized animals just prior to
euthanasia.
I declare that the animals are to be euthanized soon after tissue collection
under an approved protocol and that these are healthy animals not exposed
to any experiments and thus free from the following:






Hazardous chemicals / biochemical
Radioactive materials
Infectious agents
Human blood, body fluids and cells
Other animal cells
Recombinant DNA.
Signature:______________________
Date: __________________
Name:
Tissue Form
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NUS Institutional Animal Care and Use Committee
T00/12
Appendix 1 c
Tissue from euthanized animals obtained from protocol of other
institutions
This form is to be completed by the Principal Investigator supplying the tissue:
Name and Institution
IACUC contact/address
IACUC approved Protocol Number
Animal species
Tissues type
1. Has any of the following substances been used on the animals concerned under this protocol?
Please indicate all that apply:
Hazardous chemicals / biochemicals
Radioactive materials
Infectious agents
Human blood, body fluids and cells
Animal cells
Recombinant DNA
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
If yes, please provide name:
If yes, please provide name:
If yes, please provide name:
If yes, please provide name:
If yes, please provide name:
If yes, please provide name:
2. Have you informed your IACUC on the supply of animal tissues?
Yes.
No.
Not applicable. Approval from my IACUC not required.
3. Declaration of PI:
The applicant has my consent to collect tissues as stated above from the animals euthanized under
my protocol.
Signature : _________________
Date: _____________
Name of PI :
Tissue Form
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