ADMINISTRATIVE (MOU)
APPLICATION TO USE VERTEBRATE
ANIMALS FOR RESEARCH OR TEACHING
2015
Animal Welfare Assurance # A 3310-01
INSTRUCTIONS:
1. Verify that this is the most recent version of the Protocol
Application (see footer).
2. Submit the Administrative MOU Protocol Application with
a WSU Animal Hazardous Agents Form as well as the
associated approved protocol application (and approval
letter) from your institution via email to
IACUC@Wayne.edu. The subject line of the email should
read: “NEW MOU PROTOCOL (PI Name)”
3. You will be contacted by the IACUC Office regarding the
review of your application.
4. After you have finalized the application through the
review process, you will be instructed to submit a signed
copy of this protocol to the WSU IACUC Office.
For IACUC Office Use Only – Leave Blank
IACUC NUMBER:
Primary Reviewer:
Secondary Reviewer:
INSTITUTION:
INSTITUTIONAL ANIMAL CARE AND USE COMMITTEE
87 E. Canfield, Second Floor
Phone Number: (313) 577-1629
Protocol submission: IACUC@Wayne.edu
Section I: Administrative Data
The animal work being proposed at Wayne State University has been approved by the IACUC at an institution
with which WSU has a Memorandum of Understanding (see below).
Henry Ford Health System (HFHS)
St. John Providence Health System (SJPHS)
William Beaumont Hospital (WBH)
Other:
Protocol Number:
Protocol Number:
Protocol Number:
Protocol Number:
The Protocol and Approval Letter have been submitted with this application.
1. Principal Investigator
Name and Degree:
University Title:
Office Phone:
Primary Department/Division:
Office Address:
Cell/Home Phone:
E-Mail Address:
Laboratory Phone:
Lab Address:
Name and Degree:
University Title:
Office Phone:
Primary Department/Division:
Office Address:
Cell/Home Phone:
E-Mail Address:
Laboratory Phone:
Lab Address:
2.
Title of Project:
3.
WSU Collaborator
Not Applicable
Form Approved: April 2015
Revised: 8/2015
WSU IACUC Administrative (MOU) Protocol Application
Page 1 of 6
4.
Research Personnel: List all persons (other than the PI/Co-PI) who will work with animals on this project at WSU. Indicate which
individuals should be listed as Emergency Contacts. Emergency Contacts need to be able to authorize treatment or euthanasia in
the event that the PI/Co-PI CANNOT BE REACHED.
Name/Degree/Title
Institution
Office/Lab Phone
Home/Cell Phone
E-mail Address
Emergency
Contact
(Y/N)
Section II. – Procedures and Care
5.
Briefly describe the experimental procedures approved by your institution that will be conducted at WSU, and include the
names and responsibilities of the individuals who will conduct each procedure. The details of the experiments being conducted
at WSU should be fully described in the protocol approved by your institution’s IACUC or in a WSU-approved IACUC protocol. If
detailed experiments have not been approved by your institution, please include information about what specific procedure(s)
has been approved by your IACUC as they relate to the work being conducted at WSU.
6.
Is the work that will be conducted at WSU described in an approved WSU IACUC Protocol?
NO
YES
Protocol Number:
The protocol and approval letter must be submitted with this application.
Which procedure(s) described in the WSU protocol will be performed on the animals owned by your institution?
7.
Location where procedures will be performed:
Building(s):
Room(s):
8.
Overnight Housing: Will animals need to be maintained at WSU for more than 12 hours?
NO
YES
The PI or WSU Collaborator must contact Linda Walowicz in the Division of Laboratory Animal Resources (DLAR) at
ad0924@wayne.edu or (313) 993-4005
How long will the animals be maintained at WSU?
Form Approved: April 2015
Revised: 8/2015
WSU IACUC Administrative (MOU) Protocol Application
Page 2 of 6
DLAR will provide all husbandry and oversight.
DLAR and WSU Collaborator will share the responsibilities for husbandry and oversight.
*A Husbandry Agreement between the DLAR and WSU Collaborator must be submitted with this protocol and signed
before protocol approval.
9.
Euthanasia Methods: Will animals be euthanized at WSU?
NO (the animals will be returned to the other institution)
YES
PHS Policy on Humane Care and Use of Laboratory Animals requires the IACUC to use the recommendations of the AVMA
Guidelines for the Euthanasia of Animals: 2013 Edition; please refer to it when necessary. If anesthetic overdose or CO2 narcosis is
used, a secondary procedure such as bilateral pneumothorax, severing the aorta, or removal of a critical organ must be used to
assure that the animal will not recover.
Species
Method of
Euthanasia*
Dosage(s)
(mg/kg)
Route
Method to Assure Death
Section III. Transportation of Animals
To ensure humane animal handling and protect against disease spread, IACUC/DLAR requires that special provisions be met regarding
the transportation of animals between WSU buildings or off campus locations. Transportation arrangements can be made through
DLAR by calling 313-577-1343.
1.
State the species, strain or nomenclature, and number of animals to be transported at one time:
2.
Identify the building and room numbers involved in the transport:
Note: If animals will be taken into a WSU medical center area hospital for a procedure, you must have prior approval from the
authorizing persons at that hospital.
FROM (Institution, Building and Room):
TO (Institution, Building and Room):
Round Trip:
Yes/No
3. State the purpose of the transportation, indicate if it may be necessary to do this more than once with the same or different
groups of animals, and the length of the stay at each site (e.g., 1 hour, 6 hours, overnight, permanent).
4. Authorization to bring animals into WSU locations such as hospitals, clinics or access equipment in the WSU campus area used
for human patients. Provide details of authorization to use the facilities by the person responsible for the area(s). Include the
name and title of the individual(s), and the date authorization was obtained. Also describe how animal use locations/equipment
will be cleaned following use.
NA
Form Approved: April 2015
Revised: 8/2015
WSU IACUC Administrative (MOU) Protocol Application
Page 3 of 6
5. If animals are being transported to WSU buildings, will they come into contact with, or be housed in the same room as other
animals already residing at the destination?
No
Yes (provide details below):
6.
Will the animals need to be sedated or anesthetized prior to or during transportation? Note that large animals (e.g. dogs)
usually require sedation prior to transportation. Please consult a veterinarian if this was not previously approved by the IACUC.
No
Yes (provide details below):
Sedation and/or anesthetic
Species/Procedure
7.
Sedative
Dosage/Route/Site/
Frequency
Anesthetic
Dosage/Route/Site/
Frequency
Will the animals be transported by DLAR?
You are encouraged to make arrangements with DLAR to transport your animals by calling 313-577-1452 if you are considering
using a personal vehicle.
Yes
No (provide details below):
a.
Identify (name and contact information) of person(s) who will be responsible for the transportation of animals.
b.
If you and/or your staff will be transporting the animals, please assure the Committee that:

Animals will be transported in an appropriate climate controlled vehicle. (i.e. air conditioned/heated). The use of personal
vehicles is discouraged, as it can result in allergen exposure to the occupant and future occupants of the car, as the car can
serve as a potential reservoir of animal pathogens. During regular business hours, arrangements can be made with DLAR to
transport animals.

Animals will be transported expeditiously in a draped cage or cart by an approved route (out of public view avoiding
personnel areas such that no one is aware that an animal is being taken into the hospital area).

Animals will be hand carried between WSU buildings (the use of carts is discouraged due to uneven pavement conditions on
walkways).

Rodents will be transported in clean filtered microisolator cages and water bottles Inverted to prevent leakage.

Rodent cages will be sanitized at the destination. Rodent cage exteriors must be sprayed with bleach solution (1 part bleach
to 20 parts water) when they reach their destination. Cages cannot be opened until the bleach solution has been on the cage
for 10 minutes.
I will comply with the transportation requirements outlined above.
c.
Briefly describe transportation route below.
Form Approved: April 2015
Revised: 8/2015
WSU IACUC Administrative (MOU) Protocol Application
Page 4 of 6
Section IV. – Animal Hazardous Agents
Any research conducted at WSU involving the use of hazardous chemicals, biological agents or ionizing /non-ionizing
radiation must be approved by the applicable WSU department or safety committee. Appropriate safety procedures
and training must be documented by WSU’s Office of Environmental Health and Safety and sent to the WSU IACUC
office prior to initiation of any work performed at a WSU facility.
ATTENTION:
Please submit an Animal Hazardous Agents Form with this application as an attachment regardless of whether or not this
protocol has any identified hazards. The WSU Office of Environmental Health and Safety (OEHS) is required to review
and sign-off on every protocol prior to approval.
Form Approved: April 2015
Revised: 8/2015
WSU IACUC Administrative (MOU) Protocol Application
Page 5 of 6
V. - CERTIFICATION BY PRINCIPAL INVESTIGATOR
As principal investigator I certify to the following:
1.
My staff and I will comply with all standards for animal care and investigation established in the Guide for the Care and Use of
Laboratory Animals (the Guide, NRC 2011) and the Federal Animal Welfare Act, and will follow all policies established by the
University to assure that these standards are met.
2.
I assume responsibility for the work described here.
3.
All individuals working with the animals on this protocol are qualified by virtue of training or experience to perform proper
handling, experimental, and restraint techniques required for the species to be used.
4.
I recognize my responsibility to identify occupational health hazards related to this protocol including identifying hazards,
providing the necessary training for those involved, and supplying the appropriate protective clothing and equipment to
minimize the risks.
5.
I acknowledge my responsibility to file the appropriate paperwork (e.g. an annual inventory to the State of Michigan) if I use
controlled substances.
6.
This research does not represent unnecessary duplication of previous experiments.
7.
I realize that failure to adhere to policies related to animal care and use may result in suspension or revocation of permission
to perform animal research in Wayne State University facilities.

For additional requirements and expectations please see the Principal Investigator Responsibilities
Signature of Principal Investigator
(a faxed or scanned copy of this page is acceptable)
Date
VI. – INSTITUTIONAL ASSURANCE (IACUC Administration) – HFHS, SJPHS or WHB
I endorse the certifications made by the Principal Investigator and assure Wayne State University that the procedures have been
approved by the institution’s IACUC.
Signature of Official
(a faxed or scanned copy of this page is acceptable)
Date
Name (Type/Print)
University Title (Type/Print)
VII. - CERTIFICATION BY WSU Collaborator
I have read this protocol, understand my role in the project, and will comply with all standards for animal care and investigation
established in the Guide for the Care and Use of Laboratory Animals (the Guide, NRC 2011) and the Federal Animal Welfare Act, and
will follow all policies established by the University to assure that these standards are met.
Signature WSU Collaborator
(a faxed or scanned copy of this page is acceptable)
Date
Name (Type/Print)
Form Approved: April 2015
Revised: 8/2015
WSU IACUC Administrative (MOU) Protocol Application
Page 6 of 6