DIVISION OF RESEARCH
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Protocol #:
Approval Date:
Expiration Date:
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Submit electronically at least one week in advance of IACUC meeting date to Rebecca Thatcher, IACUC Administrative
Assistant, rthatche@clarkson.edu
followed with a signed version to the IACUC at PO Box 5630, if an electronic signature has not been provided.
Application Status: Initial Submission Renewal: (Provide previous protocol #______________)
Please note the IACUC is required to review this protocol on an annual basis.
Department:
Principal Investigator:
Mailing Address:
Telephone:
Project Title:
Funding Source:
DoR Award Number:
Fax: Email:
EXPIRATION DATE:
Name:
Contact Person:
Mailing Address:
Telephone:
OLAW Assurance Number:
AAALAC Accreditation:
USDA Registration:
Fax: Email:
Yes No
Yes No If yes, provide registration number:
Last Revised: 02/28/12
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Species Covered:
Approved Protocol
Number: (If yes, please attached protocol)
Protocol Title:
Protocol Approval Date:
If using the ascites method, does the laboratory have a policy the production of monoclonal antibodies using the ascites method, in accordance with OLAW recommendations, that require written documentation of methods used that avoid or minimize discomfort, distress, and pain (including in-vitro methods), and why the in-vitro methods has/have been found to be unsuitable? Yes No
Project Description: (Provide a brief overview of the project)
Was literature search conducted to assess commercial availability? Yes No
If so, provide data bases and dates searched.
Results of Search for Unnecessary Duplication:
Indicate whether or not the antibodies you requiring are commercially available:
If the antibodies you require are commercially available and you require custom-made antibodies, please provide scientific justification for their use in this project:
Last Revised: 02/28/12

If possible please provide the following with you request form:
(Check all provided with your request form)
Verification of PHS Assurance Number;
USDA Registration (if covered species are used in the production);
Copy of an IACUC approval letter to produce these antibodies; and
Copy of IACUC protocol.
Please note that IACUC approval may be delayed if the documents above are not provided. Additional information may be required for IACUC review (especially if the ascites method of antibody production is used).
I certify that I am the Principal Investigator of this IACUC protocol; that I am verifying that all information in the protocol is correct and accurate to the best of my knowledge.
_________________________________________ _______________________
Signature of the Principal Investigator Date:
_________________________________________
PI Supervisor:
_______________________
Date:
****************************FOR OFFICE USE ONLY****************************
REVIEW METHOD:
Full Committee Review (FCR) Designated Member Review (DMR)
IACUC APPROVAL DATE: _____________ IACUC Chair or Designee: _________________________
Last Revised: 02/28/12