INSTRUCTIONS - PLEASE READ CAREFULLY
IACUC FORMS:
1. All Institutional Animal Care and Use Committee (IACUC) forms may be downloaded from the Office of
Animal Welfare’s (OAW) website at: http://depts.washington.edu/oawhome/ .
2. Due to regulatory requirements, all questions must be answered completely. If a question or part of a
question does not apply to the project, indicate “not applicable” or “N/A”.
3. You may use additional sheets to describe animal use procedures, or you may make additional space on the
form as needed.
4. Incomplete forms cannot be approved. Please call the OAW main line at 206-685-7363 if you have
questions about this form.
SUBMISSION CHECKLIST FOR IACUC PROTOCOL REVIEW FORMS:
1. If applicable, submit a Biological Use Authorization (BUA) application to Environmental Health & Safety
(EH&S) at ehsbio@uw.edu (See Section II, Items 5 and 22 of this form).
2. Include an Environmental Enhancement Checksheet (EEC), if applicable (See Section II, Item 32 of this
form).
3. Protocol Review Forms (PRF) that involve work with non-human primates must be submitted to a
Washington National Primate Center (WaNPRC) veterinarian for review prior to submission to the OAW.
4. Submit the PRF as a PDF to the OAW via e-mail at oawsend@uw.edu. If email access is unavailable,
printed, single-sided and signed forms can be sent to Box 357160.
PRF APPROVAL PROCESS:
1. New IACUC protocols are assigned a 6 digit number. The first 4 digits indicate the PI’s name and the last 2
digits indicate, in chronological order, the specific protocol.
2. The PRF is made available to the entire IACUC in the next distribution to Committee members. This is
usually within 2 weeks of receipt of the form.
3. The IACUC may request additional information or a protocol revision, as a result of the initial review.
Written response to such requests is required - failure to respond will result in discontinuation of the review
process and the protocol will remain unapproved.
4. Any IACUC member may request discussion of the protocol at the next scheduled IACUC meeting (i.e.,
Full Committee Review or FCR). FCRs are typically conducted for protocols with substantive IACUC
questions during the initial review or for protocols with the potential for unrelieved animal pain or distress.
5. You will be notified, in writing, via e-mail, when the protocol is approved. Do not assume that you have
approval if you have not received the written approval letter.
IF YOU NEED HELP:
1. For general help/questions concerning filling out the PRF or the approval process, please call the OAW
main line at 206-685-7363.
2. For questions regarding registration for Animal Use Training sessions (AUTS) or other protocol training
requirements, refer to the AUTS website at http://depts.washington.edu/auts/.
3. For help determining animal housing and use locations in a Department Comparative Medicine (DCM)
vivarium, contact the Facilities Director at 206-543-0641or pcm252@uw.edu.
4. For help with issues such as appropriate anesthesia, analgesia, etc., contact Veterinary Services
(vsreview@uw.edu).
5. For help regarding Occupational Health, contact EH&S Research and Occupational Safety Office (206-2217770 or ohnurse@uw.edu).
6. For help regarding hazardous agents, contact EH&S Research and Occupational Safety Office (206-221-7770
or ehsbio@uw.edu).
Institutional Animal Care and Use Committee
PRF-1
Protocol #
PROJECT REVIEW FORM
Please check one:
This is a new protocol
Principal Investigator:
Phone #:
Protocol Contact Person:
or
This is a 3-year renewal
Faculty Title:
E-mail:
Phone:
Department:
FAX #:
E-mail:
Co-Investigator(s):
Project Title:
Planned Project Dates:
Funding Source(s):
Review for Scientific Merit
All animal use projects must be reviewed for scientific merit prior to initiating animal use. The required
review for this project (please check one):
Has been conducted by my department or school and has been found to be scientifically
meritorious. The review was conducted by:
Name of reviewer(s) or review committee
Name of Chairperson or designee
Will be conducted by a funding agency prior to the start of the project:
Has already been conducted and approved by a funding agency:
(Agency)
(Agency)
(OFFICE OF ANIMAL WELFARE USE ONLY - DO NOT WRITE BELOW THIS LINE)
Animal Use Categorization: ______________
CTC: _____________
Comments: _______________________________________________________________________________________
Data entry: __________________________
Date: ________________
Designated Member Reviewer: ______________________________
Date Approved by IACUC: __________
(PRF expires one year from this date)
PRF Template Revised 10-06-14
PRF-2
Institutional Animal Care and Use Committee
Principal Investigator Certification Statement
By completing and submitting this Project Review Form (PRF) I,
, do hereby certify that:
1.
I understand that all use of animals must have IACUC approval prior to animal work. I understand that
unauthorized animal use is reportable to my department, funding agencies and regulatory agencies.
Therefore, I will obtain approval prior to animal use and prior to initiating any significant
changes to the project. I understand that certain funding agencies (e.g., NIH) require specific approval
for use of their funds to cover costs incurred (i.e., per diems, salaries, etc.) during a period of noncompliance or a complete lapse in IACUC approval.
2.
I certify that this PRF accurately describes all aspects of the proposed animal use and that the proposed
work is not unnecessarily duplicative.
3.
I accept responsibility for ensuring that all personnel working on this protocol are aware of, and will not
deviate from, the IACUC approved experiments and procedures outlined on this form, that they will
adhere to the regulations regarding the humane treatment of laboratory animals and that they will
receive proper training as required by the IACUC.
4.
I understand that if I (or the contact person listed on this form) cannot be contacted and animals on this
protocol show evidence of illness or pain, emergency care, including euthanasia, may be administered
at the discretion of Veterinary Services. Please indicate contraindicated drugs under Section II, Item 31
of this form.
5.
I understand that protocol approval is not final until I receive notification in writing, via email and that
the IACUC can recommend or require changes to this protocol prior to approval.
6.
I understand that approval of this protocol is for a maximum of one year from the date of IACUC
approval and I must apply for a renewal in order to continue the protocol beyond that period.
PI signature and date (if submitting a printed copy):
PRF-3
Institutional Animal Care and Use Committee
SECTION I
A. Using language understandable to non-scientists, describe the goals and significance of the protocol
to humans, animals and science. Please provide a statement to address the potential harm to the
animals on this study (e.g., pain/distress, morbidity, mortality) relative to the benefits to be gained
by performing the proposed work.
B. If this is a 3-year renewal, please provide information requested in the next two items.
1. Have there been any unexpected, adverse events, morbidity or animal mortality in the past year? If so,
explain the cause and measures taken to prevent future occurrences.
2. Please provide a brief report of progress to date on this protocol.
PRF-4
Institutional Animal Care and Use Committee
C. Provide a description of the proposed animal studies to be conducted over the next three years or the
duration of associated grants/contracts. For each species on the protocol, in language colleagues outside
your discipline would understand, provide the sequence of events to reveal what will happen to the animals.
For complicated experimental designs, a flow chart, diagram or table is strongly recommended. Do not
describe the details of procedures here. Please note: the IACUC cannot approve your protocol unless the
entire sequence of events animals will experience is clear - from enrollment in the study to the final
endpoint on this protocol. Do not paste a grant or e-GC1 abstract.
D. Occupational Health Protocol Hazard Questionnaire (Note: Some information may be redundant with other
parts of the PRF but completion of the questions below will expedite Occupational Health review.)
Date:
New Protocol:
Contact Person:
3-Year Renewal:
Contact Person Phone:
Human tissue/cell lines
Type:
Infectious agents in animals
Type:
Toxic agents
Type:
Fixing tissues
Agent:
Chemical agents/drugs administered Type:
to animals
Using sharps
Type:
Procedures for safe needle/sharps use
and disposal
Describe:
Personal protective equipment to be
used
Type:
PRF-5
Institutional Animal Care and Use Committee
E. Personnel Information
PLEASE NOTE:
1. All individuals working with live vertebrate animals, including the PI, must complete federally required
training on pertinent laws and regulations at least every 5 years. The Animal Use Medical Screening (AUMS)
must also be completed as per the Occupational Health Nurse’s recommendations. These requirements must
be met before personnel can be approved to work on this protocol. Please see the Animal Use Training
website for more information. http://depts.washington.edu/auts/requirements.html.
2. Personnel can be added later if a person’s training has not been completed or if training has expired and is not
yet updated.
Required information for each person on the PRF:
Name:
UW (or other) e-mail:
Position:
Phone #:
Department:
Repeat this section for each species:
a. Species:
b. Years of experience with this species:
c. Indicate duties specific to this protocol:
Anesthesia*
Handling
Sedation**
Cervical
Dislocation
Husbandry and
animal care
Survival Surgery
Decapitation
Euthanasia
Orbital Bleeding
Orbital Injections
Other Duties:
*Animals are in a surgical plane
**Chemical immobilization of animals for procedures
d. Describe experience for duties listed in Item c above. If none, indicate how training will be obtained (e.g.,
will be taught by PI or personnel approved on this protocol).
e. If duties include performing survival surgery or administration of anesthesia:
i. Years of experience performing survival surgery at the UW:
ii. Years of experience performing anesthesia at the UW:
OAW USE ONLY
Laws and Regulations:
Animal handling courses completed:
Occupational Health Screening (AUMS or EHC):
Animal handling courses deferred:
PRF-6
Institutional Animal Care and Use Committee
F. Animal Housing: In the table below, list requested building and room number(s) or vivarium for
animal housing.
Species
F.a.
Yes
Housing Location (“Housing” = 12 hours or longer)
No
Have you requested housing locations that are outside a UW vivarium?
If yes, explain the scientific necessity for housing locations outside a vivarium.
Please note that regulations do not allow the IACUC to approve housing in
laboratories solely for convenience.
G. Animal Procedures: In the table below, list requested building and room number(s) or vivarium for
animal use locations including irradiation, imaging and euthanasia.
Species
G.a.
Yes
Name of Surgical and/or Nonsurgical Procedures
Location
No
Have you requested procedure locations that are outside a UW vivarium?
If yes, explain the scientific necessity for using procedure locations outside a
vivarium.
PRF-7
Institutional Animal Care and Use Committee
H. Animal Acquisition and Carry-over: Please review the following categories and complete relevant tables
for the planned number of animals for the next three years or the duration of associated grants/contracts, if
different.
a. New: Animals to be acquired from an outside vendor, another university or institution or any other non-UW
entity: (This must be coordinated through DCM or the WaNPRC.)
Species
Strains
Sex
Ages
Size
Number
b. Transfers: Animals to be acquired from another approved UW protocol: (This must be coordinated
through DCM or the WaNPRC.)
Protocol #
Species
Strains
Sex
Ages
Size
Number
c. Capture: Free-roaming animals anticipated to be captured on this protocol, including non-target species or
by-catch. You may use general classes of animals such as, “wild rodents, birds, salmonids”, rather than listing
each species. :
Species
Ages
Size
Number
d. Animals impacted but not captured or controlled by UW: Target species observed or handled, or whose
environment is affected in a manner that disrupts normal behavior or potentially causes harm or distress.
Examples include free-roaming and farm animals and animals at zoos or veterinary clinics.
Species
Ages
Size
Number
e. Breeding or Births: Animals anticipated to be born at UW on this protocol. Note: Be sure to include all
animals that will be born for use on this or other protocols, including those of incorrect gender, genotype,
phenotype, etc:
Species
Strains
Number
PRF-8
Institutional Animal Care and Use Committee
f. Carry-over: Animals currently in-house, approved on this protocol and will be continued on this protocol:
Species
Strains
Sex
Ages
Size
Number
g. TOTAL animal numbers for parts a-f (should match the total given in Item N.)
Species
Animals ordered/acquired through:
DCM
WaNPRC
Other
Veterinary care provided by:
DCM
WaNPRC
Other
Total number
by species
Note: Provide the name, credentials and contact information, if veterinary care will not be provided by DCM or
the WaNPRC:
I. Replacement, Refinement and Reduction: Federal policies require documentation that replacement,
refinement and reduction (“The Three Rs”) of animal use have been addressed. For all studies, a literature
search (or other documentation) is required to determine that:
1) There are no non-animal alternatives available AND
2) That less painful/distressful alternatives to this proposed animal use are not available or feasible.
Was a literature search performed? Yes
No
If yes, provide the following information:
Databases/Sources
Searched
Date of Search
Years of Search
Key search words or strategy to find
alternative to animals AND potential
alternatives to painful/distressful
procedures
J. If a literature search was not performed: Please describe, in detail, the methods used to determine that
alternatives to the proposed use of animals or those less painful/distressful procedures are not available or
feasible. It is not sufficient to simply state that there are no alternatives. You must explain how you know
this to be the case.
PRF-9
Institutional Animal Care and Use Committee
K. Ascites: Federal policies require that investigators planning production of monoclonal antibodies by the
mouse ascites method specifically address the reasons that in vitro methods cannot be used. NOTE: If the
antibody is commercially available as an “off-the-shelf” product, the ascites method cannot be used in lieu
of purchasing the antibody.
L. Describe alternatives to animal use that may employ (or have employed) on this project: Alternatives
should reflect refinement, replacement and reduction of animal use. These include in vitro tests, use of less
sentient animals, use of fewer animals to attain statistical significance and use of methods to decrease
animals’ sensitivity to pain.
M. Describe the rationale for using animals and the appropriateness of the species proposed:
N. Animal Numbers Requested: Provide in detail the method used to determine the number of animals you
will need for the next three years or the duration of associated grants/contracts. If preliminary data are
available for the necessary calculations, inclusion of a Power Analysis is expected. For studies where Power
Analysis is not appropriate (e.g., pilot studies, tissue protocols, etc.), provide a narrative describing how
requested animal numbers were determined. Be sure to explain how experimental groups, group sizes, etc.
were determined. A statement such as, “We will use 5 animals per group and 3 groups and therefore need
15 animals.” is not sufficient.
PRF-10
Institutional Animal Care and Use Committee
SECTION II
ANIMAL USE PROCEDURES: Mark “Yes” or “No” for each item listed below. If an item is marked
yes, answer each part of the item, and if parts are not applicable to the project, type “N/A”.
Please review IACUC policies regarding specific procedures.
facilitate review and approval of the protocol.
Yes
No
Adherence to approved policies will
If public release of this form is requested under the Freedom of Information Act,
I wish to have input to ensure that information revealing the experimental hypotheses
or design is not released to the public.
**Repeat each item as necessary for each species on this PRF**
#
Yes
No
1.
Anesthesia (Include pre-anesthetic and anesthetic agents):
a. Provide the information requested in the table below.
Species
Anesthetic
Agent
Dose
(mg/kg or %)
Route
Procedure
(e.g., surgery, blood draw)
b. For gas anesthesia, what is the method for scavenging waste gases (e.g., F/AIR canister,
fume hood, etc.)?
c. What parameters will be monitored to ensure adequate anesthesia throughout the
procedure (e.g., corneal reflex, heart rate, respiration, front toe pinch for
Ketamine/Xylazine, etc.)?
2.
Ether use (not recommended)
a. Scientific justification for use of Ether (required):
b. Fume evacuation method:
c. Most recent certification date of fume hood:
d. Room where Ether will be used:
e. Storage method and location:
PRF-11
Institutional Animal Care and Use Committee
#
Yes
No
3.
Paralytic agents - Anesthesia is required
a. Agent:
b. Dose(s):
c. Volume(s) (required for rodents only):
d. Route:
e. Approximate duration of procedure:
f. Frequency:
g. What parameters will be monitored to ensure adequate anesthesia throughout the
procedure (e.g., corneal reflex, heart rate, respiration, etc.)?
h. Scientific justification for use of paralytic agents:
4.
Administration of drugs or reagents
**For hazardous agents complete Item 5 instead of Item 4. For antibody or ascites production,
complete Item 8 or 9.**
a. Agent:
b. Dose(s):
c. Volume(s) (Required for rodents only):
d. Route:
e. Frequency and duration of administration:
f. Intended effects on animals:
g. Potential side effects on animals:
h. Monitoring protocol, including frequency, duration and specific behavioral and clinical
signs to be monitored:
5.
Potentially hazardous agents
NOTE: Include all hazardous chemicals, biohazardous agents and radioactive materials used in
animals. Working with biohazardous agents, requires a separate approval from the Institutional
Biosafety Committee (IBC). Submit the Biological Use Authorization (BUA) paperwork to
initiate this process. If you have questions, contact EH&S Research and Occupational Safety at
206-221-7770 or ehsbio@uw.edu.
a. Agent:
b. This is a:
Biological Hazard
Chemical Hazard
Radiological Hazard
c. Dose(s):
d. Volume(s) (required for rodents only):
e. Route:
f. Frequency and duration of administration:
g. Intended effects on animals:
h. Potential side effects on animals:
i. Monitoring protocol, including frequency, duration and specific behavioral and clinical
signs to be monitored:
j. Potential danger to humans:
k. Precautions to protect personnel:
PRF-12
Institutional Animal Care and Use Committee
#
Yes
No
l. Containment requirements:
6.
Toxicity testing
a. Agent:
b. Testing protocol:
c. Intended effects on animals:
d. Potential side-effects on animals:
e. Monitoring protocol, including frequency, duration and specific behavioral and clinical
signs to be monitored:
f. Endpoint:
Euthanasia
Spontaneous Death
Other (explain)
7.
Will you administer cells, cell lines sera or other biologicals to rodents?
a. If yes, please contact the Rodent Health Monitoring Program (RHMP) (206-221-3933 or
rhmp@uw.edu) regarding the cells to be used on this project to determine what testing may
be required prior to administration to rodents.
I have already contacted RHMP and discussed this issue.
I have not yet contacted RHMP but will prior to starting this work.
8.
Antibody production (For ascites production, skip to Item 9 below.) (Note: If you plan to
purchase custom antibodies from a private company instead of producing them yourself, you do not
need to answer this question. However, the company you use must have an Animal Welfare
Assurance on file with the Office of Laboratory Animal Welfare (OLAW). Most assured companies
are listed at: http://grants1.nih.gov/grants/olaw/assurance/300index.htm)
a. Provide the information requested below if you will be using animals to produce
antibodies.
Immunizing
Agent (Antigen)
Adjuvant
Number and
Site(s) (IP, IM, SQ,
etc.) of inoculation
Volume per
inoculation site
Primary
Immunization
Booster
Immunization
9.
Ascites production
a. Priming agent (e.g., Pristane):
b. Volume (Not to exceed 0.2ml of Pristane for mice):
c. Route:
d. Hybridoma cell injection protocol (e.g., dose, number of days after priming):
PRF-13
Institutional Animal Care and Use Committee
#
Yes
No
e. Monitoring protocol, including frequency, duration and specific behavioral and clinical
signs to be monitored. The minimum monitoring requirement following initial
inoculation is 3 times/week, the first week and daily thereafter:
f. Ascites collection protocol, including number of taps, needle size, etc. Euthanasia is
required after the second tap, unless scientifically justified:
10.
Tumor transplantation/induction or spontaneous growth
a. Type of tumor - for implants specify species of origin (e.g., human, mouse):
b. Site:
c. Functional deficits expected:
d. Monitoring protocol, including frequency and specific behavioral and clinical signs to be
monitored. Per IACUC policy, animals must be observed 2-3 times per week until
clinical signs occur and daily thereafter:
e. Provide assurance that animals will be euthanized before tumors exceed 10% of normal
body weight or provide scientific justification for larger tumors:
11.
Blood sampling
a. Method:
b. Site:
c. Volume (Describe monitoring/replacement therapy if volume is greater than 10ml/kg per
2 week period.):
d. Frequency:
12.
Imaging procedures (radiographs, ultrasounds, MRI, etc.)
a. Be sure to list the imaging location in Section I, Item G of this form.
b. Imaging type:
c. Will animals be anesthetized (If yes, be sure to list anesthetics in Section II, Item 1):
d. Frequency:
e. Duration of each imaging session:
f. Purpose (e.g., imaging only, tumor treatment, etc.):
g. Will supportive care of animals be necessary? If yes, describe:
13.
14.
Use of restraint
**Not applicable for brief restraint such as holding for blood sampling or anesthetized
procedures.**
a. Method (including device type/name and/or description):
b. Frequency:
c. Duration of restraint:
d. Scientific justification for prolonged or painful restraint:
Implanted catheters, prostheses, etc. (Describe applicable surgery in Section II, Item 16)
a. Type:
b. Site:
c. Maintenance and care of chronic implants:
PRF-14
Institutional Animal Care and Use Committee
#
Yes
No
d. Method used to sterilize implants:
e. Monitoring protocol, including frequency and specific behavioral and clinical signs to be
monitored:
f. Will it be necessary to surgically re-implant or repair implants, if they fail? If so, please
describe the circumstances that would require a repair or replacement. (Include request
for repair surgeries in the applicable sections of the multiple survival surgeries table in
Section II, Item 16.):
15.
Terminal surgery (i.e., no recovery from anesthesia)
a. Describe surgical procedure:
b. Duration of procedure:
16.
Survival surgery
a. Name of surgery:
b. Number of surgeries per animal:
c. Describe surgical procedure(s):
d. Pre-operative protocol (e.g., food/water restriction, animal prep, etc.):
e. Aseptic precautions (Must include method of instrument sterilization prior to initial use
and between animals, if applicable.):
f. Confirm that you will use sterile surgical gloves (if not, provide the rationale) and a face
mask. Note other items as required for your surgeries (e.g., sterile surgical gown, etc.):
g. Supportive care during procedure (e.g., IV fluids, if needed):
h. Duration of procedure:
i. Post-surgical, recovery period monitoring protocol (Provide continued monitoring
protocol in Item 17 below):
j. Time point for suture/staple/clip removal (If this is greater than 14 days, an explanation is
required.):
k. Deficits expected as a result of the surgery:
l. Multiple Survival Surgeries: Provide scientific justification for multiple survival
surgeries on a single animal and length of time between surgeries.
Name of surgery 1:
Name of surgery 2:
Name of surgery 3:
Continue listing additional
surgeries as necessary:
Time between Surgery 1 and 2:
Time between Surgery 2 and 3:
Continue with time between
additional surgeries:
Rationale for multiple surgical
sessions in a single animal:
PRF-15
Institutional Animal Care and Use Committee
#
Yes
No
17.
Potentially painful procedure - Applicable for all procedures that would be considered painful
in the absence of anesthesia or analgesia (e.g., survival surgery, bone marrow aspirates, noxious
injection, adjuvant, etc.).
a. Analgesic:
b. Dose:
c. Volume (required for rodents only):
d. Route:
e. Frequency:
f. Monitoring for analgesic efficacy: include frequency, duration and specific behavioral
and clinical signs to be monitored:
g. Scientific justification if analgesics are to be withheld from animals with signs of pain:
18.
Capture/Trapping (Note: Obtaining required permits is the responsibility of the PI and is
required prior to start of a project.)
a. Capture/Trapping protocol:
b. Duration animals will be in traps or restrained:
c. Indicate non-target species that may be inadvertently captured:
d. Disposition of animals (e.g., euthanized, released, etc.):
19.
Special diet (e.g., high fat, etc.)
a. Composition of diet:
b. Amount:
c. Duration:
d. Intended effects on animals:
e. Potential side-effects on animals (e.g., anticipated weight loss or gain, dehydration, etc.):
20.
Food/Water restriction of 12 hours or more for experimental purposes
a. What is restricted?
b. Duration of each restriction event and frequency:
c. Anticipated side-effects (e.g., anticipated % weight loss, dehydration, etc.):
d. Monitoring protocol to ensure food/fluid intake meets animal need, including frequency,
duration and specific behavioral and clinical signs to be monitored:
e. Scientific justification for restriction:
f. Scientific justification for weight loss greater than 20% of baseline or controls:
21.
Behavior testing
a. Describe testing procedures, including equipment to be used, stimuli and restraint:
b. Scientific justification for use of noxious stimuli:
22.
Genetically manipulated animal use or production
The following situations require approval from the Institutional Biosafety Committee (IBC):
1) Animals other than rodents: Production/use of genetically manipulated animals (e.g., fish).
PRF-16
Institutional Animal Care and Use Committee
#
Yes
No
2) Rodents: Breeding experiments involving genetically manipulated rodents that contain more
than 50% of the genome of an exogenous eukaryotic virus from a single family OR
breeding experiments in which the genetically manipulated rodent’s transgene is under the
control of a gammaretroviral long terminal repeat (LTR) OR breeding experiments in which
the genetically manipulated rodent’s transgene encodes for the secretion of a toxin with an
LD50 of <100 ng/kg.
If yes to 1or 2 above, submit an IBC Biological Use Authorization (BUA) Application or
Request for a Change to BUA form to initiate the approval process:
http://www.ehs.washington.edu/rbsresplan/bua.shtm.
a. Based on the above, is IBC Approval required? Yes
No
b. Method of production (e.g., embryo transfer, superovulation procedures, breeding, etc.):
c. Method of genetic verification (e.g., age, amount of tissue, etc. and include anesthetics, if
used):
d. Anticipated effects of genetic manipulation (e.g., spontaneous death, tumors, etc.):
e. Monitoring protocol, including frequency and specific behavioral and clinical signs to be
monitored:
f. Disposition of non-genetically manipulated animals (e.g., use as controls, euthanasia, etc.):
23.
Breeding colony that will supply other protocols or research institutions
a. Breeding method (e.g., pair, harem):
b. Protocol (e.g., randomizing procedures, breeder culling criteria, etc.):
c. For inbred animals, specify the number of generations from source:
d. For outbred stocks, specify method to ensure lack of inbreeding:
e. List any other quality control procedures:
f. For inbred strains, provide a description of record systems and documentation of animal
pedigrees, production and disposition:
24.
Will some animals live out their natural life spans as a part of this project?
a. Indicate use of these animals (e.g., breeders, blood donors, experimental animals, etc.):
b. Will you be housing older animals (e.g., rodents greater than 18 months of age)? If yes,
describe monitoring protocol for older animals, including:
1. Frequency, intervals, duration:
2. Behavioral and clinical signs monitored:
3. Care and treatment given, including criteria for euthanasia:
25.
Spontaneous death of animals, rather than euthanasia, as an experimental endpoint
(e.g., toxicity studies, LD50 studies, etc.)
a. Scientific justification (required) including the reason(s) euthanasia is not possible:
b. Monitoring protocol, including frequency and specific behavioral and clinical signs to be
monitored:
PRF-17
Institutional Animal Care and Use Committee
#
Yes
No
26.
Non-physical euthanasia, such as CO2 or drug overdose
a. Agent (drug, dose, route) for non-physical euthanasia:
b. If using CO2 or gas overdose, describe the secondary form of euthanasia:
c. Criteria used to decide upon euthanasia (e.g., tissue harvest, end of study, etc.):
d. For studies in which animals may become ill, indicate the specific behavioral and clinical
signs used as euthanasia criteria:
e. Scientific justification for methods not approved by the AVMA Guidelines on Euthanasia
(2013) https://www.avma.org/KB/Policies/Documents/euthanasia.pdf:
27.
Physical euthanasia on anesthetized or awake animals
a. Method (e.g., cervical dislocation, decapitation, etc.):
b. Will the animal be anesthetized prior to physical euthanasia? If yes, indicate the
anesthetic to be used and make sure to include it in Section II, Item 1.
c. Personnel performing procedures (Must be certified - Contact auts@uw.edu for
information on certifications):
d. Criteria used to decide upon euthanasia (e.g., tissue harvest, end of study, etc.):
e. For studies in which animals may become ill, indicate the specific behavioral and clinical
signs used as euthanasia criteria:
f. Scientific justification for methods not approved by the AVMA Guidelines on Euthanasia
(2013):
28.
Collection of body fluids (i.e., urine, saliva or feces) or tissue samples from live animals
**If survival surgery is involved complete Section II, Item 16 instead of this question.**
a. Time point(s) for collection:
b. Tissue(s) to be collected:
1. Tissue collection method, describe aseptic procedures, if applicable.
2. Number of samples for each tissue site and time point:
29.
Other procedures: Please think through your planned studies and describe any live animal
procedures you have not already described elsewhere on this form.
30.
Training/Practice procedures: Will you be using animals to train personnel or practice
procedures that are included in this protocol? If so, you must include these animals in
Section I, Items C, H and N of this form.
31.
Are there any medications or procedures that should not be administered by veterinary
personnel because they would render the results of the study invalid? If so, list them
here:
PRF-18
Institutional Animal Care and Use Committee
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32.
Yes
No
Environmental Enhancement Checksheet
NOTE: A new Environmental Enhancement Checksheet (EEC), if required for the species,
must be submitted for each new IACUC protocol or 3-year renewal. The checksheets are
located on the OAW’s IACUC forms page: http://depts.washington.edu/oawhome/forms/#EEC.
Please complete the appropriate EEC(s) and attach it/them to this form.
Note: The IACUC cannot review the protocol without the EEC forms, if they are
necessary.
33.
Identification of individual animals (other than cage cards)
a. Method(s) (e.g., ear punch/tag, tattoo, tagging/banding, radio collar, etc.) (Note: If method
is implantation (e.g. PIT tag), describe procedure in Section II, Item 14. If method is
surgical (e.g., satellite tag), describe the surgery in Section II, Item 16.):
b. Will external identification be replaced if it falls off/out? If yes, describe the plan for
replacement:
c. Will external identification be removed as part of the protocol (e.g., radio collars on field
animals)? If yes, describe the plan for removal:
34.
Transportation of animals outside of UW buildings
a. From where to where? (For field research, the generic “field location” is sufficient):
b. Transportation method? (e.g., vehicle, hand carry, wheeled cart, etc.):
c. Will a private vehicle be used to transport animals? (Note: All motor vehicles require
IACUC approval prior to use.)
d. Type of enclosure, if applicable (e.g., cage, transport bucket, etc.):
e. How is climate controlled during transport?
f. How are animals and/or their enclosure secured during transport?
g. For extended transport times, how will the animals’ well-being be monitored and needs
provide for, including food and water?
35.
Gamma irradiation, linear accelerator, etc.
Requires EH&S Radiation Safety approval. Contact radsaf@uw.edu or call 206-543-0463
a. Be sure to list irradiation location in Section I, Item G of this form.
b. If partial-body irradiation, please describe:
c. Dose range:
d. Frequency and intervals, if repeated sessions:
e. Post irradiation monitoring protocol, including frequency, duration and specific
behavioral and clinical signs to be monitored:
f. Describe the reconstitution plan:
g. Will animals be treated with antibiotics?
1. Antibiotic:
2. Dose range (and volume for rodents):
3. Route:
4. Frequency, intervals and duration:
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Institutional Animal Care and Use Committee
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36.
37.
Yes
No
Is there expected mortality (spontaneous death) associated with any of the procedures
listed on this protocol, other than as planned and described in Section II, Item 25 ?
a. Procedure associated with mortality:
b. Estimated mortality rate, i.e. percentage of animals expected to die spontaneously (not via
euthanasia) or need to be euthanized as a result of the procedure. Be sure to account for this
in your animal number calculations in Section I, Items H and N:
c. Explain why euthanasia is not possible or appropriate:
Expected final disposition of animals on this protocol. Check all that apply:
a. Euthanasia:
b. Spontaneous death:
c. Transfer:
d. Return to colony (NHPs only):
e. Other (adoption, release, please explains):