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
http://hms.harvard.edu/hma iacuc@hms.harvard.edu
ANNUAL REVIEW FORM
Fax Number:
Phone Number:
Protocol Number:
Date Approved:
Date Due:
Principal Investigator:
Title of Protocol:
Please complete the information requested below and submit a pdf version to IACUC@hms.harvard.edu.
A. What is the status of your animal protocol (circle one)? PENDING
ACTIVE
CLOSED
If closed, please indicate closure date above, sign and date this form and return to this office immediately.
B. Where are your research animals housed?
Bldg.
Rm(s).
C. Where are your animal procedures performed for this protocol? Bldg. ____________ Rm(s). ___________
D. Are you using the ascites method of monoclonal antibody production? YES
NO
(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.)
E. Describe the funding for your study: Funding Agency
Grant Title
Grant Number
F. Rodent Breeding Colony users only: Any changes to the original estimated numbers of animals in breeding colonies
must be reported. These numbers must be also be tracked on a log sheet in the animal housing room. If there are no
changes in these numbers, please leave this section blank. Non-rodent or non-breeding-colony animal number
increase requests must be submitted via an amendment form.
i.
Additional breeding adults requested per year:
ii.
Additional offspring requested per year:
iii.
iv.
Additional offspring euthanized without research use (pain category B):
State total annual number of breeding colony animals being requested (i-iii):
v.
Indicate the highest pain category that these animals will fall under (if genotyping by tail biopsy animals
must be placed under category D or higher).
vi.
Justify the number of ADDITIONAL breeding colony animals to be used (the number of animals must
be appropriate for the work being proposed. Provide groups and statistical analysis to be used if
relevant.):
HMA IACUC Annual Renewal Form
Revised October 3, 2013
Page 1 of 4
G. USDA-covered species
NO____
YES____
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:
i. Describe the use of your animals over the course of the past year, including the number of animals
used:
ii. Describe any adverse events in the past year:
iii. If you currently hold an exemption to animal care 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 renewed annually. If so, please
1. Briefly describe the Exemption you hold and whether you intend to continue its use:
2. Justify the continuation of the exemption:
H. If you have approval for and are using aquatic species, you must describe the number of animals used in the past year:
a. FISH: ____
b. FROGS: ____
c. Other aquatics: ____
Sign below and return a pdf version of this form to IACUC@hms.harvard.edu
PI Signature:
Date:
Based upon the information given above, this protocol has been found acceptable for renewal for ONE YEAR
Reviewed by IACUC Member : ___________ Date: ____________
Signature of IACUC Chairman:
Renewal Date
HMA IACUC Annual Renewal Form
Revised October 3, 2013
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, listed below,
certify 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. 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 procedure related to this animal protocol. ONLY those listed will be considered ACTIVE on the
protocol. Others will be removed from the protocol.
NB: Clinical staff members that do not have substantial, direct, intellectual contributions to the work do not need to be listed.
Name / Degree
Position on Protocol
Experience/training working with species &
procedures
Phone & email
AALAS Online Learning
Library Training Date(s)
Update Departed Personnel: ____________________________________________________________________________________
HMA IACUC Annual Renewal Form
Page 3 of 4
Revised October 3, 2013
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
http://hms.harvard.edu/hma
iacuc@hms.harvard.edu
MEMORANDUM
To:
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 a pdf version of the Annual Review Form to
IACUC@hms.harvard.edu before the due date noted on it (usually 7-10 days before the expiration date
of your protocol). Amendments to protocols must be submitted on an Amendment Form obtained from:
http://hms.harvard.edu/departments/hma-standing-committee-animals/forms
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, available at
http://hms.harvard.edu/departments/hma-standing-committee-animals/forms.
HMA IACUC Annual Renewal Form
Revised October 3, 2013
Page 4 of 4