St Vincent’s Hospital (Melbourne)
Animal Ethics Committee
Module A
This module should accompany your application which has been printed from TierBase.
Completing Module A
Answer all questions. Attachments must be labeled with the question numbers and question titles.
The application form has been set up so that data is entered into text fields. Text fields appear on
the screen as grey boxes. Click on the grey box to enter a response.
Please ensure that all signatures and any handwritten information are done in BLACK INK
for better photocopying quality.
Contact person
Secretary of the Animal Ethics Committee
Research Governance Unit
Email: research.ethics@svhm.org.au
Phone: 9288 2394
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St Vincent’s Hospital (Melbourne)
Animal Ethics Committee
Module A
Project details
This is a:
New project
Renewal of existing project, protocol number -
PROJECT TITLE:
Principal Investigator:
Department / Unit:
Affiliated organization:
Scientific Procedures Premises Licence (SPPL) Number:
SPPL Organisation Name:
Project details
1.
Location
Where will the procedures be performed? Please include location and room numbers.
2.
Use of genetically modified organisms
2.1 Does the project involve the use of genetically modified organisms? Yes
No
2.2 If yes, state the Institutional Biosafety Committee (IBC) identification number IBC
Please note: Researchers using Genetically Modified Organisms (GMOs) and / or genetically
modified animals should seek AEC approval first and when provisional approval has been
obtained then an application to the IBC should be submitted referencing the AEC Protocol
number. Once the IBC has approved the project the letter of approval will be issued from AEC.
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3.
Use of human tissue
3.1. Does the project involve the use of human tissue?
Yes
No
3.2. If yes, state the Human Research Ethics Committee reference number: HREC
Please note: If you do not have an HREC reference number, you need to submit an application
to the HREC as soon as possible. AEC applications will not be approved until the HREC has
approved the application.
4.
Fieldwork
‘Fieldwork’ applies to Scientific Procedures conducted at premises not listed on a license and
can be conducted under a SPPL or SPFL.
Does the protocol involve Fieldwork (ie taking animals to another campus) as part of the
project?
Yes
No
Please note: Please attach a Field Work Notification form to your application.
5.
Yes
No
Does the protocol involve the use of radiation?
Complete Section 5
Proceed to Question 6
5.1.
Does the research involve the use of radiation on site at St Vincent’s Hospital (Melbourne)?
Yes
No
If yes, attach a report from the St Vincent’s Hospital (Melbourne) Radiation Safety Protection
Officer or refer to the appropriate SOP in the application.
5.2
Does the research involve the use of radiation at a site other than St Vincent’s Hospital
(Melbourne)?
Yes
No
If yes, attach a report from the Radiation Safety Protection Officer from that site. The report must
include
∙If using radiation equipment, confirmation that the equipment is registered with the Department of
Health
∙Confirmation that the site has the appropriate policies and procedures in place.
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RESOURCES AND SUPPORT FROM OTHER DEPARTMENTS
6.
Funding
6.1. Has the project received funding?
Yes
No
6.2. Is the funding from an external source?
If yes:
Administering Institution:
Funding agency:
Reference number:
Yes
No
6.3. Is the funding from an internal source?
Yes
No
If yes:
Source:
Reference number:
7.
Are the services of other campus departments, including the BioResources Centre,
Medical Imaging and Pathology, required?
Yes
No
If yes, attach completed Signature Page 2 for each department.
8.
For each Investigator who is not known to the AEC, and who will be directly
involved with live animals, attach a statement of experience in animal experimental
procedures and animal handling including the species and procedures involved. DO NOT
include a C.V.
Will you need to attach such information?
If yes, name the Investigator(s)
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Yes
No
HEAD OF DEPARTMENT DECLARATION:
Signature Page 1
Handwritten information and signatures to be completed in BLACK INK only
PROJECT TITLE:
I hereby declare that:
1.
I have read the protocol and understand my responsibilities with respect to the animal
experimentation components described in this project;
2.
I have read the Prevention of Cruelty to Animals Act 1986 (the Act) and the NHMRC
Australian code of practice for the care and use of animals for scientific purposes, 7th Edition
2004 (the Code);
3.
I accept responsibility for the conduct of the experimental procedures detailed above in
accordance with the principles contained in the Act and Code and any other conditions laid
down by the Animal Ethics Committee of St. Vincent's Health; and
4.
This project will be conducted in accordance with any Code of Conduct for Scientific Research
Practice in use by St. Vincent's Health
SIGNATURE: __________________________________ Date: ________________
NAME:
DEPARTMENT:
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DEPARTMENTAL ASSISTANCE WITH RESEARCH PROJECT:
Signature Page 2
This form is to be given to the Head of the assisting Department(s) by the Principal Investigator.
Please complete handwritten information and signatures in BLACK INK only
FROM:
Assisting Department:
EMSU
Other
BioResources Centre
If Other, give details
PROJECT TITLE:
PRINCIPAL INVESTIGATOR:
I have discussed this study with the principal investigator and have seen the application.
I am (please tick):
 Able to perform the investigations / services
indicated within the present resources of the
Department.
Yes
No
 Able to perform the investigations/services if the
following financial assistance is provided (specify
the investigations/services and estimated costs):
Yes
No
 Unable to undertake the investigations/services on the following grounds:
SIGNATURE: ____________________________________
NAME:
Date: ________________
____________________________
Head of the assisting Department of _________________________________
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