Revised May 2009
Official IACUC Office use only
IACUC Number ________________
UNIVERSITY OF PENNSYLVANIA IACUC PROTOCOL REVIEW FORM-Form A-2006
This form is for all new protocols and 3 year de novo reviews.
All protocols must be typed. Submit the original signed protocol, and one electronic copy sent to
IACUC@pobox.upenn.edu to the Director of Animal Welfare, 3624 Market St., 301 S, Ph.: 215.898.2615.
Protocols must be approved by the IACUC prior to the initiation of any investigation or teaching activity
involving vertebrate animals. The IACUC Office will forward the protocol to all relevant secondary reviewers
(e.g. EHRS, ULAR, etc.).
Protocol Title:
Grant title (if different from protocol title):
a. Estimated dates of protocol: From
To
b. Funding Source:
this protocol).
, Grant #:
(Not to exceed 3 years)
(Please submit a copy of the grant minus appendices with
c. Institution # (from Office of Research Services-(ORS)) Required for all sponsored research
proposals:
(Contact your BA or call ORS at 215-898-7293 to find out your number)
d. Is this protocol part of a funded or non-funded RO1, training, center, or program grant? Yes
. If Yes, Title:
P.I.:
, No
Answer only those that apply: (check off answer with an “X”)
a.
b.
Is this a new protocol submission? Yes
Is this a 3-year resubmission? Yes
If yes, Protocol #
Principal Investigator (PI):
Dept.:
IACUC Policy on who may be a Principal Investigator on a Protocol.
Responsible Organization Number (Required-Four digit #):
Campus Address:
Lab Location:
, email:
Co-Investigator:
Campus Address:
Lab Location:
, email:
Intramural Mail code:
Lab. Phone w/area code:
Office Phone w/area code:
Emergency Phone # (not work) w/area code:
Dept.:
Intramural Mail code:
Lab. Phone w/area code:
Office Phone w/area code:
Emergency Phone # (not work) w/area code:
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Revised May 2009
 Day to Day Contact Person (this person should be routinely available by telephone):
Dept.:
Phone w/area code:
Emergency Phone # (not work) w/area code:
email:
If the principal investigator is a department chair, the Dean's signature must be obtained. If the study involves
two departments, both Chairs’ signatures are required.
Dept. Chairperson (Type Name)
Dept.
Dept. Chairperson (Signature)______________________________________ Date ___________
Dept. Chairperson (Type Name)
Dept.
Dept. Chairperson (Signature)______________________________________ Date ___________
Dean (Print Name)
School
Dean (Signature)_________________________________________________ Date ___________
SECTION I: GENERAL INFORMATION
Refer to IACUC Guides (“Guidelines”) which can be found on the Regulatory Affairs web site
(www.upenn.edu/regulatoryaffairs) for guidance when completing this form.
1. Goals and/or Benefits Of The Proposed Research in Lay Language
Provide the goals of the experiment. Include all anticipated benefits. This must be explained in terms that can
be understood by a lay person without a scientific background. “Procedures involving animals should be
designed and performed with due consideration for relevance to human or animal health, the advancement of
knowledge, or the good of society.”(Limit: half page)
2. Protocol Category - See Assigning Pain and Distress Levels To Animal Use Protocols for a more complete
description
A. Please assign this protocol a pain/distress category using the Penn categories (A, B, C).
Category A
No pain or distress beyond that involved in the restraint, injections, or collection of
samples. An example of this level is tissue harvest (taking tissues from animals which have been
euthanized following the 2000 AVMA Guidelines and exsanguination under anesthesia).
Category B
Potential for pain/distress but relief is provided by anesthetic/analgesic/tranquilizing
drugs as appropriate-see below***. Please note that the USDA has defined any surgery as potentially
painful (this includes both survival and non-survival surgery). Other examples include: antibody
production, tumor production, perfusion, and use of neuromuscular blocking agents (NMBs)*** ).
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Revised May 2009
Category C
Pain or distress not relieved by sedatives or analgesics (see below***). Provide a
scientific justification as to why you cannot use sedatives or analgesics. This justification may be included
on the University's USDA Annual Report, which is available to the public through the Freedom of
Information Act.
*** The following protocols will be sent by the IACUC staff to a ULAR veterinarian for their
comments:
1) All Category C protocols
2) All Category B protocols that use USDA covered species;
3) All protocols that employ neuromuscular blocking agents.
*Protocols requiring veterinary review will not be reviewed by the IACUC until the veterinarian’s
comments have been received.*
B. There is
is not
an alternative or alternative method (tissue culture, computer models, bacterial
cultures etc.) available for this proposed work that does not require the use of living animals. If there is,
why must you use animals?
C. Does this research duplicate previous work? YES
, NO
If yes, why is this duplication necessary?
D) If this protocol is categorized as level "B" or "C", by law you must consider alternatives to potentially
painful/distressful procedures. See Guideline 18. In the following section, check which of the following
databases and other sources have been searched to assure that the proposed experiments do not unnecessarily
duplicate previous experiments, do not cause undue distress or pain, and that alternative species or alternative
methods have been considered and are not available. The search should include “refining” by using less
stressful procedures, “replacing” the species selected, with one lower on the phylogenetic scale, and
“reducing” the number of animals you are requesting. The search should have been conducted within the last 3
months.
Literature Search
Check
Database
Date Search Performed
(X)
Medline
Agricola
Current Research Information System(CRIS)
Biosis/Life Science
CAB Abstracts
Embase
Altweb
(http://altweb.jhsph.edu/)
Years Covered
3
Revised May 2009
Association of Veterinarians for Animal
Rights
http://www.avar.org
(For Teaching Protocols)
Literature Review
Other(s)
You must provide a written narrative of the methods and sources used to consider alternatives to procedures
for research and teaching that may cause pain or distress to the animals. Please include your search strategy
along with the key words and linked key words. The following key words are provided as suggestions to use
when looking for alternatives: “animal model, animal testing alternative, animal alternative, and invitro techniques”. Whether one or more of these terms are used or whether more suitable words of your
choice are used, the search must reflect a sincere effort to consider alternatives. Alternatives to both the
animal model and the procedures being used must be addressed in the literature search. Therefore, include
in your search words EACH PROCEDURE that has the potential for causing pain/distress to the
animal.
Search Results:
For help with your literature search or additional databases contact the Animal Welfare Information
Center at www.nal.usda.gov/awic/databases/database.htm or (301) 504-6212 or
awic@nal.usda.gov.
3. Description Of The Proposed Research
Describe in general terms what procedures will be performed. The following items should be included; the
experimental design (including treatment groups and appropriate controls); the endpoint of the experiment; and
any unusual procedures not covered in any of the IACUC Guidelines.
4. Species, Species Justification, and Total Number Of Animals
A. Provide the total number of animals anticipated to be used for the approval term of this protocol (not to
exceed 3 years). Please include those animals that will be 1) “procured” i.e., purchased and/or obtained from
outside the University (approved animal breeders or other institutions), 2) “transferred” from other protocols
(list protocols, if applicable), or 3) “produced” within this protocol (breeding). All animals, regardless of
their source, must be ordered or transferred through the ULAR Procurement Office: 215898-2564.
Species and strain
Number Procured
Number Transferred
(include protocol #)
Number Produced
Total #=
Total #=
Total #=
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Revised May 2009
Grand
total/species=
B. Species Justification
Provide separate justification for each species listed on the protocol. Why must you use the species you have
requested? (A separate justification must be provided below for each species.)
C. Animal Numbers
What is the scientific justification for the number of animals to be used (i.e. statistical validity, previous
experience, etc.)?
Please be aware of the following when planning your experiments:
 Limit animal involvement by using the minimum number required to obtain reliable results.
 Use non-animal methods, such as mathematical models, computer simulation, or in vitro biological systems
if possible.
 Avoid or minimize animal discomfort, distress, and pain as in consistent with sound scientific practices.
 Use appropriate sedation, analgesia, or anesthesia when your procedures will cause more than momentary
pain or distress. Do not perform surgical, or other painful procedures on non-anesthetized animals.
 In addition, include information such as the number of control and experimental groups, number of animals
per group or other reasoning.
 A table/flow chart describing experimental groups and controls MUST be provided.
5. *UPDATED* Protection of Humans – Use of Substances Potentially Hazardous to Humans
Animal genus and species used in this protocol:
Please indicate if you will be using the following in animals:
A. Microbiological Agents: (i.e. bacteria, viruses, parasites, fungi, etc)
Yes
No
Please list:
1.
2.
3.
4.
5.
B. Human Source Material: (human blood, tissue, cells, or body fluids)
Yes
No
If yes, please describe:
C. Tumor cell lines:
Yes
No
If yes, please indicate cell line source and description:
Human
Non-human primate
Other
Description
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Revised May 2009
D. Recombinant DNA (rDNA):
1. Does this protocol involve the generation of rDNA or the use of rDNA in animals?
Yes
No
If yes, please list the rDNA construct(s) and IBC number(s) in table below.
2. Are you using rDNA for the DEVELOPMENT of genetically modified animals (includes
transgenics, knock-outs or -ins, etc.)?
Yes
No
If yes, please list the rDNA construct(s) and IBC number(s) in table below.
3. Does this protocol involve the BREEDING of genetically modified animals to produce a new
strain of genetically modified animals?
Yes
No
Please describe:
4. Please provide all information below from a current IBC approval letter.
Note: All recombinant DNA (including purchased or gifted rDNA) must be registered with the
IBC prior to generation and/or use, and must be renewed every 3 years. Registration forms and
NIH guidelines can be found at the EHRS website
(http://www.ehrs.upenn.edu/protocols/rDNA.html):
Construct Name
IBC #
BSL
ABSL
E. Biosafety Levels: Please indicate the biosafety level and animal biosafety level at which you will be
working.
Biosafety Level:
1
2
3
Animal Biosafety Level:
1
2
3
N/A
F. Transport of Animals:
1. Will animals be taken out of the animal housing facility?
Yes
2. Will animals be moved through patient areas?
Yes
If yes to questions 1 and/or 2:
Indicate the rooms/buildings involved:
Indicate type of containment to be used for transport:
G. Hazardous Materials:
1. If this protocol involves the administration or treatment of live animals with hazardous
chemicals, toxins, anesthetics, and/or drugs, please list in the table below.
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Revised May 2009
Substance
Dose
Route of Administration
Poses hazard to humans
through direct or
indirect contact with the
animal and/or its
bedding (Yes or No)
2. Describe how the hazard will be controlled for all substances in the chart above that poses a
hazard to humans:
3. If this protocol involves the use of inhalation anesthetic, please indicate a waste anesthetic gas
scavenging method:
Active scavenging with a vacuum system
Filtering with charcoal canister
Used in a fume hood or a Class II type B biosafety cabinet
Other (describe):
4. If this protocol involves the perfusion of animals larger than rodents, indicate where the
perfusion will take place:
H. Radioisotopes
Yes
If radioisotopes are used, a radiation Protocol Summary Form
(http://www.ehrs.upenn.edu/programs/radiation/licensing.html) must also be submitted to EHRS.
Isotope(s):
Licensee Name:
Activity administered per animal:
Where will radioisotope administration occur? Bldg:
Rm.#:
Will animals be returned to their original facility?
Yes
No
If no, please provide the Bldg.
Rm.#
and contact ULAR Rodent Quality Assurance
prior to irradiation and complete the appropriate transfer forms and bleeding procedures
(215.898.4008).
I. Irradiation
Yes (x-ray irradiators fill in “X-Rays/CT section below)
Irradiator Licensee:
Location of Irradiator:
Name of Users:
Will animals be returned to their original facility?
Yes
No
If no, please provide the building room #
and contact ULAR Rodent Quality Assurance
(215-898-4008) prior to irradiation and complete the appropriate transfer forms and bleeding
procedures.
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Revised May 2009
J. X-Rays/CT
Yes
Please indicate the type of equipment:
Radiographic X-Ray
Computed Tomography
X-Ray Irradiator
Other (please specify):
Location of machine:
Fluoroscopy
Cabinet X-Ray
K. Lasers
Yes
1. Laser manufacturer and model #:
2. Maximum power output:
3. Operational power:
4. Mode of operation (continuous wave or pulsed):
5. If pulsed, pulse width:
Pulse repetition frequency:
6. Exit beam diameter:
7. Delivery method (i.e. fiber):
8. Building and room number where laser will be used:
9. Names of personnel who will operate laser:
6. Protection of Animals—Use of Substances Potentially Infectious to Animals. [ULAR
Rodent Quality Assurance required]
All protocols using any of the materials below must be reviewed and approved by the University Laboratory
Animal Resources (ULAR) Associate Director for Diagnostic Services and Rodent Quality Assurance prior
to final approval by IACUC. Submit one copy of the protocol to the ULAR, Attention Rodent Quality
Assurance, 177E Old Vet Quadrangle, 3800 Spruce St., mail code 6009 or by FAX: 215-746-4146. For
questions, call 215-898-4008.
Answer all questions below that apply:
a. Surveillance testing of cells, plasma, tissues of animal (including human) origin to be injected into
rodents. To prevent the possible spread of pathogens into our rodent colonies, all cells, plasma,
tissues of animal or human origin and passed through a rodent, and that are to be injected/inoculated
into any rodent must be tested for possible contamination by certain infectious agents. Please refer
to the University of Missouri PCR Profile Impact II for Mice and Impact VI for Rats at
www.radil.missouri.edu for a description of infectious agents.
Test results must be submitted to the ULAR Associate Director for Rodent Quality Assurance or
his/her designee for review and approval.
1). What procedure (PCR, MAP, RAP Testing etc.) was done to evaluate this tissue for possible
contamination?
Origin of
Material
Test(s)
Performed
Date
Laboratory
performing test
Test result
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Revised May 2009
2). How is this tissue being maintained? Frozen and/or in tissue culture?
Note: If the tissue is being maintained in rodents in a facility other than that in which the recipients are
housed, permission MUST be obtained from the Associate Director or his designee for housing these
recipient animals.
Note: Tissues that tested positive may still be used but must be used in containment with arrangements
made with the Associate Director or his designee.
b. Use of agents that are potentially infectious to other animals.
All agents that are potentially infectious to other animals in the colony must be listed in this section
and approved by the Associate Director for Diagnostic Services and Rodent Quality Assurance.
Agent
Natural host(s)
List any species the agent has the potential to infect including people
7. Removal Of Animals From Housing Facility
A. In which animal facility will the animals be housed (if known)?
B. Will animals be taken out of the animal housing facility? YES , NO
If “YES”, please include all buildings and room numbers in Question 10 “Procedure Checklist”. If the
procedure is not included, please use the “Other” box to provide the information.
C. Transport of Animals
1) What type of containment will be used for transport?
2) Will animals be transported outdoors? YES
, NO
If ”YES”, please refer to Guideline 16.
3) Will animals be transported through Human Patient Areas**? YES
If “YES” please complete the chart below.
Species
, NO
Patient Area
**Before receiving IACUC approval, the Principal Investigator must provide written permission from the
HUP Infection Control Office, 9 West Gates/4283, 215.622.6995 or the Presbyterian Infection Control
Office at 215.662.9260, describing the route to the location where the animals will be used.
9
Revised May 2009
D. Will live animals be returned to the original housing facility? YES
If “NO”, where will animals be returned to? Building
Room
, NO
and Why?
If the animals need to go to a different facility, transfer forms must be submitted to the ULAR procurement office
and approved by the Diagnostic services office (www.ular.upenn.edu).
For guidance on the removal of infected animals from containment or their transport through human patient areas, consult
Guideline 16, available at our web site, IACUC Guidelines and Policies
8. Occupational Health Program- [Form E Required]
The Occupational Health Forms (IACUC Form E and IACUC Form E-NBC) are available at IACUC Forms
and
MUST be completed and submitted with the protocol. Provide information for each individual with animal
contact. “Animal contact” is defined as contact with the animal itself and unpreserved animal products (e.g.,
tissues, body fluids, discharges, urine, blood or feces) or items contaminated by these products. Return ONLY
one copy of the Occupational Health Form to the Office of Regulatory Affairs with the original protocol.
This form can be obtained at our web site: IACUC Forms
If this protocol is classified as an Animal Biosafety Level 2 or higher risk category, you and your staff are
encouraged to participate in the Animal Handler’s Occupational Health Program. If you are using non-human
primates, it is mandatory that you and your staff participate in the Animal Handler’s Occupational Health
Program and send the IACUC confirmation on a yearly basis with the protocol renewal form. To arrange
for a consult, contact Occupational Medicine and Health Services at HUP at 215.662.2354.
9. Personnel, Qualifications and Training- It is the responsibility of the Principal Investigator to assure that
all personnel performing any procedures on animals receive the proper training (items a-d below).
A) List all personnel that will be working with animals and/or animal by-products. In addition, the Principal
Investigator and all co-investigators should be listed and their roles described even if they are not handling the
animals or animal by-products.
Name
Position
Penn ID number*
IACUC on-line
orientation **
Yes or No
ULAR “Hands on
training”
Yes or No
(see 9c)
*The Penn Card ID # is the eight digit number sequence on your Penn ID card.
**Required
for
ALL
personnel
every
three
years:
Please
visit
our
web
site
(www.upenn.edu/regulatoryaffairs) for the information on the on-line IACUC Orientation course and the
ULAR “Hands on Training” information.
B). Personnel Qualifications: List the qualifications of each of the individuals above (9a). Be sure to include:
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Revised May 2009
degree(s), years of experience with the species, and skills and specific procedures described that they will
participate in (i.e. surgery, blood draw, injections, euthanasia, tissue harvest, imaging, etc.). If an individual is
not working with animals and/or animal by-products please describe their role in the project. If individuals do
not possess the appropriate qualifications and/or skills, please indicate how they will be trained.
C). Animal Handling: If you have never worked with the species in this proposal at the University of
Pennsylvania and/or have never taken the ULAR “Hands On Training” course for the species listed in
this protocol you will need to be certified in animal handling/procedures. If the individual is not working
directly with the animals or animal by-products, hands on training is not required. For information and to
register for the next available hands on training class please see the ULAR website, www.ular.upenn.edu.
Space is limited so you MUST REGISTER.
Special technique training will be provided by qualified individuals listed on this protocol OR arranged
through the ULAR Training Division (www.ular.upenn.edu). All training must be documented and
faxed to the ULAR Training Division at
215-573-9998 .
d). All personnel who work in laboratories are required to attend annual health and safety training. EHRS will
notify the principal investigator if all participants are not current in health and safety training. For information
about training requirements and schedules, consult the EHRS web site, http://www.ehrs.upenn.edu/.
11
Revised May 2009
SECTION II: SPECIFIC PROCEDURES
10. Procedure Checklist.
Please check the procedures to be used in this protocol and provide detailed information in the appropriate
section. Those questions already checked off must be answered.
Check
(X)
x
Procedure
11
12
13
14
15
16
17a
17b
17c
18
19
20
21
22
23
24
25
26
27
28
29
30
Other
Building
Room
#
Tissue Harvest (removal of tissue from dead animals)
Imaging Studies
Use, Production of Rederivation of Transgenic Animals
Animal Identification
Use and/or Production Of Monoclonal Or Polyclonal Antibodies
Blood Collection
Survival Surgical Procedures
Terminal non-Survival Surgical Procedures
Multiple Surgical Procedures
Pharmaceutical Grade Agents
Non-surgical Procedures With the Potential for Pain and Distress
Use Of Neuromuscular Blocking Agents
Prolonged Physical Restraint & Restriction of Movement
Capture/Restraint of Wildlife
Tumor Production
Food &/Or Water Restriction
Catheterization or Instrumentation in Animals
Special Housing and Husbandry Procedures
Special Diets
Footpad Injection
Drug license and location information
Final Disposition of Animals and/or Euthanasia (mandatory)
Briefly Describe Procedure
11. Tissue Harvest –performed on non-living animals (for methods of euthanasia see Question 30)
Yes
a. Tissues/Organs/Body Fluids being harvested include:
b. What method of euthanasia will you be using? (please include dose and route of administration)
12. Imaging Procedures

A. Location – If you are using a Small Animal Imaging Facility, please contact Sallie Livingston,
SAIF Coordinator, Dept. of Radiology, at Sallie.Livingston@uphs.upenn.edu to apply for all of the imaging
procedures below.
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Check (X) Procedure
MRI / MRS*
PET
SPECT
CT
Optical
Ultrasound
Other
Location
Species
(list all that
apply)
Duration of
Imaging
HUP - Founders
Richards 5th Floor
Richards 5th Floor
Richards 5th Floor
CRB 437A
Stemmler 342
Building
Room
* Before receiving IACUC approval for MRI / MRS usage, the Principal Investigator must provide written
permission from the HUP Infection Control Office, 9 West Gates/4283, Phone 215.662.6995 to the Office of
Regulatory Affairs.
For guidance on the removal of infected animals from containment or their transport through human patient
areas, consult Guideline 16, available at our Guidelines and Policies page.
B. Description of Procedure –
a. Please describe the imaging procedure(s) including anesthetics (dose, route), and transport of the
animals (route, enclosure, how animal will be monitored, etc.). If multiple imaging procedures are
to be done please give details regarding the sequence of events and time course (hours, days)
between imaging.
In addition for SPECT and PET imaging please go to
(http://www.ehrs.upenn.edu/programs/radiation/licensing.html) and submit a Protocol Summary
Form to EHRS (may be submitted electronically).
b. Will the animals be euthanized at the conclusion of each procedure?
YES
NO
If “NO” and the species is MICE and/or RATS, the animals must remain in the designated
Richards Small Animal Imaging Facility (SAIF). Please contact ULAR Rodent Quality
Assurance prior to imaging and complete the appropriate transfer forms and bleeding procedures
215.898.4008.
If “NO” and species is anything other than mice and rats, arrangements must be made through
ULAR procurement (215) 898-2564 as to where the animals can be housed.
13. Use, Production, or Rederivation of Genetically Modified Animals, i.e., any animal in which there has
been a deliberate introduction or removal of genetic information by experimental manipulation (includes
transgenics, knock-outs or ins, etc.)
A. Does this protocol involve the USE of genetically modified animals? YES
, NO
1. If this protocol involves the USE of genetically modified animals previously developed, please provide
the name of the Principal Investigator and institutional affiliation of the source (include Penn protocol # if
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Revised May 2009
applicable):
or state where they are purchased from: (Vendor name):
2. Describe the phenotype of each strain used and list any conditions that are not normal in healthy animals
and what course of action will be taken to relieve any pain/distress:
B. Does this protocol involve the DEVELOPMENT or REDERIVATION of genetically modified animals?
YES
, NO . If animals will be developed, Institutional Biosafety Committee (IBC) and EHRS approval
are required. For rederivation, EHRS approval is required. Submit a recombinant DNA registration document
(http://www.ehrs.upenn.edu) and a copy of the animal protocol electronically to EHRS
(approvals@ehrs.upenn.edu).
1.
YES
I am producing my own animals. If YES, you must request, in question 4,
the necessary number of animals required to develop the founders or to re-derive.
2.
YES
Transgenic Core Facilities with approved IACUC protocols will produce the
foundation breeders/perform the re-derivation.
Protocol number of transgenic core:
3.
Since these animals may develop behavioral or physical conditions that are not normal
in a healthy animal, do you anticipate any such conditions? YES
, NO
If yes, please
describe the following:
a. Potential abnormal phenotypic conditions and how frequently there are abnormal phenotypic
conditions :
b. How often will the animals be observed? :
c. Action to be taken to relieve pain/distress (eg. Euthanasia/call ULAR vet/analgesia):
C. Method Used for Genotyping: Please indicate what method you will use to sample the DNA from the
animals. Please see Rodent Genotyping Methods and Rodent Identification
Methods for guidance.
14. Animal Identification – ALL SPECIES *UPDATED*
For rodents, see Rodent Identification Methods for guidance.
1.
2.
Micro-Tattooing: Requires ULAR “Hands On” training and may require anesthesia. Please indicate
what type of anesthesia you will use along with the dose and route. Proof of “hands on training” should
be submitted with this protocol.
MicroChip Please describe:
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Revised May 2009
3.
Ear-tagging Please describe:
4.
5.
6.
Ear-punching: Only to be done on weaned rodents. Please describe:
Toe Clipping: A method of identification of small rodents, should be used ONLY when no other
individual identification method is feasible and should be performed ONLY on altricial neonates. (i.e.
animals considered helpless and whose eyes have not yet opened ; Mice < 12 days old and Rats < 7 days
old. Please provide a scientific justification for using this method:
Other: Please describe:
15. Use and/or Production of Monoclonal or Polyclonal Antibodies IN LIVE ANIMALS. *UPDATED*
I will produce monoclonal or polyclonal antibodies:
A. YES
, NO
If yes, I will follow MonoClonal Antibody Production and
Polyclonal Antibody Production as appropriate. If you will not be following the
guidelines, please describe the process you will follow:
B.
YES
, NO
Complete Freund’s Adjuvant will be administered. Please refer to The Use
Of Complete Freund's Adjuvant in Laboratory Animals.
Provide scientific
justification for use of Complete Freund’s Adjuvant:
C.
YES
, NO
Are you producing monoclonal antibodies using the mouse ascites method? If
yes, you must scientifically justify your use of the ascites method and explain why in-vitro alternatives
cannot be used. Please read MonoClonal Antibody Production prior to answering this
question.
D.
YES
, NO
I am purchasing monoclonal or polyclonal antibodies to be used in animals from
a commercial source. I understand that I must purchase from sources with a PHS Assurance
Statement and/or a USDA license as appropriate.
16. Blood Collection See Blood Collection for guidance.
Species:
Anatomic Site:
Volume collected:
(ml/kg)
Bleeding interval/frequency:
Note: Maximum allowed in any 3 week interval is 10 ml/kg.
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Revised May 2009
Method of restraint used for blood collection:
NOTES:
Retro-orbital bleeding requires anesthesia. Indicate the dose of injectable or inhalation anesthetic agent to
be used.
If >5 ml/kg (0.5% of the body weight) is collected at one time it is recommended that the total volume be
replaced with sterile fluids given SQ or IV. This is mandatory in USDA covered species (everything
except mice, rats, fish and birds).
Scientific justification must be given to exceed the above guidelines.
17. Survival Or Non-Survival Surgical Procedures *UPDATED*
ALL SURVIVAL SURGERIES must be done in a manner that will maintain a sterile surgical field.
Rodent Surgery and Post Anesthetic Monitoring and USDA Species Surgery Guideline describe the techniques
that must be followed in rodents and USDA covered species, respectively. ALL SURVIVAL SURGERIES must
include a provision of peri- and post-operative analgesia, as determined by the surgical model and in
consultation with a ULAR veterinarian. See Rodent Anesthesia and Analgesia Formulary for additional
guidance for rodent surgery. All survival surgeries in any species must be done in IACUC approved surgical
facilities using aseptic technique.
Note: A ULAR veterinarian’s review is required for all surgeries (see Section I).
A. Category
Check Appropriate Surgery:
Species
Type of Surgical Procedure
Terminal (non-survival) surgery will be performed.
Survival surgery will be performed once per animal
Multiple survival surgery will be performed
Non-survival second surgery will be performed
B. Location
Check (x) or Provide Appropriate Location of Surgery and Records: 1) All of the locations below require semi-annual inspections by the IACUC
SOM-ULAR Surgery Suite-Richards 7th Floor
SOM-ULAR Surgery –Stemmler 5th Floor
SOM-ULAR BRB 3 Surgery
SVM-VHUP 4115 floor
SVM-Student Surgery 2107
SVM-ULAR Surgery Vet. 273E-C & 272E-D
SVM-NBC Hospital Surgery
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Revised May 2009
SVM-Vet Rodent Procedure Room 269E
Investigators Lab. Bldg./Rm. No.
If other, specify
2) Where are the surgical and post-op records maintained? Building:
Room:
C. Anesthetic/Analgesic Regimen
Pre-Anesthetic/Analgesic, Anesthetic Agents & Intra-Operative Analgesic
Species
Preanesthetic
agent
mg/kg
Preanalgesic
agent
mg/kg
Anesthetic:
Induction
Dose
(mg/kg or
% gas)
Anesthetic:
Maintenance
Dose (mg/kg
or % gas)
IntraOperative
Analgesic
mg/kg
Route
1) Describe below how you will determine depth of anesthesia and how it will be increased if necessary.
2) Description of the surgical procedure MUST be provided. Include description of preparation of the
surgical site, anesthesia, peri-operative analgesia (for survival surgery), the actual procedure, and method
of closure. Please include if there is an expected mortality rate with this procedure. You may add an
additional page if needed.
3) Based on the surgical procedure (e.g. cardiovascular or cardiopulmonary manipulation, cerebral vascular
catheterization, etc.) do you anticipate the possibility of sudden death during the post-operative period?
Yes
, No
. If yes, please describe.
4) Do you anticipate the need for postoperative support? Yes
, No
If Yes, complete “5” below.
If NO, how will you observe and monitor the animal(s) during the post operative period?
5)
I anticipate that post-operative care will be required. Describe post-surgical care, including (1)
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Revised May 2009
clinical signs of post-operative pain, (2) frequency and time course of observations, and (3) person(s)
who are responsible for post-operative care, observations, and record keeping. Do not include “PRN” or
“as needed” without describing pain assessment criteria.
Post-Operative Analgesics and Sedatives (Guideline 12, “Post-operative Surgical Care”)
Species
Agent
Dose mg/kg
Frequency of Adm.
6) Multiple Survival Surgeries: Please justify the need for multiple survival surgeries.
18. Pharmaceutical or Better Grade Agents will be used Yes
No
If NO, describe reasons here
and explain how the drug will be prepared in a sterile fashion?
Non-pharmaceutical grade drugs may only be used if pharmaceutical grade or better agents are not
commercially available. All drugs must be used prior to their expiration date.
19. Non-surgical Procedures With the Potential for Pain and Distress: Yes
a) Describe the procedure(s). Please include dose and route of anesthetic agents, if applicable.
b) Describe the clinical signs of pain/distress associated with the procedure(s).
c) Describe the frequency of observation, the endpoint of the experiment and the person(s) who will
document these observations:
d) Describe all treatment(s) to provide relief. If treatment cannot be provided due to the nature of the study
this becomes a Category C. (See Question 1)
If the treatment includes drugs, complete the chart below:
Analgesics and Sedatives
Species
Drug
Dose (mg/kg)
Route of Adm.
Frequency
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Revised May 2009
20. Use Of Neuromuscular Blocking Agents: [ULAR Veterinary Approval required] The use of
neuromuscular blocking agents (paralytics/NMBs) in any experimental protocol requires appropriate
justification. Such agents will not be approved for use without adequate anesthesia/analgesia AND appropriate
detailed procedures that definitively demonstrate that appropriate anesthesia/analgesia is maintained throughout
the duration of action both prior to and during the use of the neuromuscular blocking agent. See Use of
Neuromuscular Blocking Agents in Animals for guidance and specific requirement for using NMBs.
Yes
Please answer the following:
Paralytic agent:
Dosage:
Route:
Frequency:
a) Give scientific justification for its use.
b) Describe how the animal will be monitored and precautions you will take to insure the animal is under
anesthesia and does not suffer pain or distress.
c)
Pilot study data is attached to the protocol submission.
21. Prolonged Physical Restraint & Restriction of Movement (Prolonged Restraint): Yes
Describe the method of restraint, including duration and frequency, and how the animal will be monitored.
Explain why restraint is required.
22. Observations, Capture and/or Restraint of Wildlife: Yes
If applicable, describe field studies.
Have all applicable governmental permits been obtained? Yes
, No
.
If no, please explain.
Otherwise please provide copies with this protocol.
23. Tumor Production: Yes
YES
, NO
: If yes, I will follow guidance in Tumor Load Studies.
If the answer is NO, please explain how this protocol differs. How you will evaluate the pain/distress to
which the animals are subjected? How you will alleviate those conditions?
A.
B.
As stated in IACUC Guideline 2 Tumor Load Studies, the PI will assure that animals involved
in tumor load studies are monitored for tumor growth, pain, and distress a minimum of two times per
week during the study by qualified laboratory personnel. Yes
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Revised May 2009
24. Food &/Or Water Restriction: Yes
YES
, NO
If yes, I will follow Food and Water Restriction.
If NO, describe here why the Guideline for Food/Water Deprivation cannot be followed. Indicate the duration,
frequency and the possible outcomes.
25. Chronic Catheterization Or Instrumentation In Animals: Yes
Describe catheterization or instrumentation and include site preparation (clipping, sterile preparation), maintenance
and local anesthetic if required.
26. Special Housing and Husbandry Procedures: Yes
Special housing and husbandry includes:
- reduced cage sizes
- overcrowding
- housing for immune-compromised
- single housed animals
- modified light cycles
- modified behavioral enrichment procedures
- 12-hour housing outside of the animal facility
- Wire-bottom or metabolic cages
The facility supervisor needs to be notified, prior to their initiation, if any of these special housing and
husbandry procedures are to take place in the animal facility.
Provide a complete description and justification.
Locations where animals will be housed outside of the animal facility for more than 12 hours,
a. MUST be inspected by the IACUC and approved PRIOR to relocating the animals.
Please call 215-746-6271 for an appointment. Housing Laboratory Animals in the Study
Area.
b. You MUST complete ONE COPY of Guideline 25- Requests for Housing of Animals within the Study
Area (Laboratory) Application Form Request for Housing of Animals Within a Study
Area
27. Special Diets: Yes
The Animal Facility Supervisor should be notified prior to initiating the study.
a) Detail the composition of the special diet and any special requirements needed.
b) Who will prepare the diet and how often will the animals be fed?
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Revised May 2009
c) What will be the consequences of the diet change imposed?
28. Footpad Injection: Yes
If the protocol involves injection of an agent into the FOOTPAD of animals, please provide a scientific
justification and describe the steps you will take to reduce pain/distress in the animals and how the animals will
be monitored:
29. Drug license and location information:
Policy on Expired Drugs and Materials
a. Where are all drugs, controlled and non-controlled, kept for in vivo use? Building (s)
#(s)
.
and room
b. Are you using controlled substances? Yes , No . If yes, please list the substance(s) here
provide the name of the individual who holds the Drug Enforcement Agency (DEA) license
apply for a license with the DEA please go to this link
http://www.deadiversion.usdoj.gov/drugreg/index.html.
and
. To
30. Final Disposition Of Animals and/or Euthanasia –(MANDATORY)
At the end of the experiment the animal(s) will be:
a)
Transferred live to another protocol. Protocol #
The Animal Transfer Form is available
from the animal facility supervisor or from the ULAR web site at http://www.ular.upenn.edu.
This form MUST be completed in order to transfer animals from one protocol to another.
b)
Placed for adoption (contact a ULAR veterinarian and see the IACUC adoption policy)
c)
Released into the wild. Please describe how this will be done.
d)
Euthanized (MANDATORY: you must answer all applicable questions below)
If the *AVMA Panel on Euthanasia is not being followed, you must provide a scientific
justification:
*These guidelines are available through links to the ULAR and Regulatory Affairs web sites
(http://www.ular.upenn.edu, and www.upenn.edu/regulatoryaffairs)

Overdose of a barbiturate or euthanasia solution (# of mg/kg)
Agent:
Dose (mg/kg):
 CO2
(Dry Ice as a CO2 source is NOT permitted).
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Revised May 2009
 Other:

The methods below require pre-sedation or justification for not administering sedatives:
Check if you will use:
Decapitation
Cervical Dislocation
Exsanguination
Please describe your method of sedation:
The PI acknowledges that he/she is the responsible individual for this protocol, and all workers
with animals in his/her laboratory will be trained in examining and recognizing the loss of vital
signs (heart beat and respiration) to ensure that the animals is fully euthanized.
PI must Initial with pen here ____________.
SECTION III: INVESTIGATOR’S CERTIFICATION STATEMENT AND SIGNATURE
Principal Investigator Certification and Signature
1. I certify that appropriate pain-relieving drugs have been or will be used throughout the entire study to
relieve pain or distress whenever it occurs, including postoperative or post procedural care, unless
specifically stated otherwise in this protocol.
2. I further certify that the activities in this protocol do not unnecessarily duplicate previous experiments.
3. I certify that all personnel performing any procedures on animals will receive the proper training and will
participate in the training programs available (IACUC, EHRS and ULAR-hands on training). A description
of this training and experience is provided in this protocol. Proof of such training for all personnel and
myself will be provided to the IACUC upon request.
4. I understand that it is my responsibility as the Principal Investigator to ensure that all individuals listed on
the protocol have read and understand the procedures described for each species.
5. I am not using radioactive materials, infectious agents or other biologically or chemically hazardous
materials in the animal facility other than those included in this protocol and approved by the EHRS.
6. I agree to abide by the provisions of the PHS policy, USDA-APHIS regulations, and the NRC “Guide for
the Care and Use of Laboratory Animals.”
7. If I wish to change any of the procedures or personnel as shown on this protocol, I will request IACUC
approval by submitting the details of the change(s) as an amendment to ORA. If necessary, I will submit a
new protocol.
8. I understand that any failure to comply with the guidelines and requirements of the
IACUC may result in suspension of my studies and notification to the funding agency, the
PHS and /or the USDA as mandated by law.
9. I understand that animals on this protocol may be used to train personnel listed on this protocol to fulfill
the basic species-specific hands-on training requirements and/or for protocol-related technique training by
qualified personnel listed on this protocol or arranged through the ULAR Training Division.
10. I certify that all work described in the grant application or award listed on the face
page of this protocol is described fully in this protocol.
_________________________________________________________
______________________________
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Revised May 2009
Signature of Principal Investigator
Date
23