A-PLAC
NEW PROCEDURE
AMENDMENT
Title page filled out
Procedure Type:
Ascites Production (Mab)
Blood Collection
Breeding
Immunization (Polyclonal Ab)
Eae Induction
Non-Surgical Anesthesia
Surgical Procedure
Transgenic/Es Procedure
Tumor induction/Passage
Other
Procedure Relationships [to existing procedures]
Pain/Distress [D or E]
page has definitions of categories
Euthanasia
Title Page
So they can be sure of assigning the new species to the correct protocol, please fill
out.
DATE:
Title of protocol:
Director (PI):
PROTOCOL # (if known):
Procedures
Enter X beside each procedure protocol you wish to submit and then include the page
with the appropriate questions.
Ascites Production (Mab)
Blood Collection
Breeding
Immunization (Polyclonal Ab)
Eae Induction
Non-Surgical Anesthesia
Surgical Procedure
Transgenic/Es Procedure
Tumor induction/Passage
Other
Ascites Production (Mab)
Procedure Title:
Species:
Pain Category(C,D,E):
Procedure Description:
Non-surgical Drug Use
Agent:
Dose Range (in mg/kg if possible):
Route:
Frequency:
Agent:
Dose Range (in mg/kg if possible):
Route:
Frequency:
Agent:
Dose Range (in mg/kg if possible):
Route:
Frequency:
Route: 1) inhalation (IN), 2) Intacardiac (IC), 3) Intradermal (ID)
Blood Collection
Procedure Title:
Species:
Pain Category(C,D,E):
Procedure Description:
Non-surgical Drug Use
Agent:
Dose Range (in mg/kg if possible):
Route:
Frequency:
Agent:
Dose Range (in mg/kg if possible):
Route:
Frequency:
Agent:
Dose Range (in mg/kg if possible):
Route:
Frequency:
Route: 1) inhalation (IN), 2) Intacardiac (IC), 3) Intradermal (ID)
Breeding
Procedure Title:
Species:
Pain Category(C,D,E):
Procedure Description:
Non-surgical Drug Use
Agent:
Dose Range (in mg/kg if possible):
Route:
Frequency:
Agent:
Dose Range (in mg/kg if possible):
Route:
Frequency:
Agent:
Dose Range (in mg/kg if possible):
Route:
Frequency:
Route: 1) inhalation (IN), 2) Intacardiac (IC), 3) Intradermal (ID)
Non-Surgical Anesthesia
Procedure Title:
Species:
Pain Category(C,D,E):
Procedure Description:
Non-surgical Drug Use
Agent:
Dose Range (in mg/kg if possible):
Route:
Frequency:
Agent:
Dose Range (in mg/kg if possible):
Route:
Frequency:
Agent:
Dose Range (in mg/kg if possible):
Route:
Frequency:
Route: 1) inhalation (IN), 2) Intacardiac (IC), 3) Intradermal (ID)
Surgical Procedure
Procedure Title:
Species:
Pain Category(C,D,E):
Procedure Description:
Location (Bldg/Room):
Type (M-multiple major survival surgery, S-survival, T-terminal):
If animals will NOT be attended at all times during the surgery, state the reasons below:
Surgeon Name (from personnel list on protocol):
Prior experience with this surgery with this species? (Y/N):
Relevant Degree:
Years Experience w/ Animals:
This species:
Surgeon Name (from personnel list on protocol):
Prior experience with this surgery with this species? (Y/N):
Relevant Degree:
Years Experience w/ Animals:
This species:
Pre-Anesthetic:
Agent
Dose Range (in mg/kg if possible):
Route:
Anesthetic
Agent
Dose Range (in mg/kg if possible):
Route:
Paralytic
Agent
Dose Range (in mg/kg if possible):
Route:
Postoperative Care if Survival Surgical Procedure
Location:
Monitor By Whom:
Frequency:
Analgesic
Agent:
Dose Range (in mg/kg if possible):
Route:
Frequency:
Treatment
Agent:
Dose Range (in mg/kg if possible):
Route:
Frequency:
Multiple Major Survival Surgery
Same as initial surgical procedure(Y/N)?:
Provide justification for MMSS and describe procedural differences below:
Non-surgical Drug Use
Agent:
Dose Range (in mg/kg if possible):
Route:
Frequency:
Agent:
Dose Range (in mg/kg if possible):
Route:
Frequency:
Agent:
Dose Range (in mg/kg if possible):
Route:
Frequency:
Transgenic/ES
Procedure Title:
Species:
Pain Category(C,D,E):
Procedure Description:
Non-surgical Drug Use
Agent:
Dose Range (in mg/kg if possible):
Route:
Frequency:
Agent:
Dose Range (in mg/kg if possible):
Route:
Frequency:
Agent:
Dose Range (in mg/kg if possible):
Route:
Frequency:
Tumor Induction/Passage
Procedure Title:
Species:
Pain Category(C,D,E):
Procedure Description:
Non-surgical Drug Use
Agent:
Dose Range (in mg/kg if possible):
Route:
Frequency:
Agent:
Dose Range (in mg/kg if possible):
Route:
Frequency:
Agent:
Dose Range (in mg/kg if possible):
Route:
Frequency:
Other
Procedure Title:
Species:
Pain Category(C,D,E):
Procedure Description:
Non-surgical Drug Use
Agent:
Dose Range (in mg/kg if possible):
Route:
Frequency:
Agent:
Dose Range (in mg/kg if possible):
Route:
Frequency:
Agent:
Dose Range (in mg/kg if possible):
Route:
Frequency:
Procedure Relationships
If more than one surgery or procedure will be performed on some or all animals used
under this protocol, please describe the sequence and timing of these manipulations. Use
enough detail to allow reviewers to understand what each experimental group might
experience. PLEASE NOTE: If multiple major survival procedures are to be performed,
you will be asked for specific justification elsewhere in this form.
Pain/Distress Categories D or E
If at least one procedure has the potential for category D or E. Please complete the
following narrative:
I have performed the following database searches (database title and keywords):
Date of Search:
Years covered in search:
Based on
years of experience in this field in conjunction with periodic consultation
of the following bibliographic sources:
and a number of references including these major journals:
I believe there is no alternative to this procedure that may involve pain/distress to the
animals. Based on the aforementioned references and experience, this animal model is the
most appropriate for conducting my research.
Pain/Distress Category E
Explain why drugs cannot be used to fully alleviate pain/distress. Include the species
and number of animals affected.
USDA Pain/Distress Category Definitions:
Category C
no pain/distress and no use of pain-relieving drugs (routine procedures, injections and blood
sampling)
Category D
pain/distress for which appropriate anesthetic, analgesic, or transquilizing drugs are used
Category E
pain/distress for which the use of appropriate anesthetic, analgesic, or tranquilizing drugs are
withheld due to adverse effects on procedures, results or interpretations
Euthanasia
Species:
Method:
IF you have chosen a physical method.
Please provide scientific justification for using it as the sole means of euthanasia or
describe how animals will be sedated or anesthetized with another agent prior to its use.
If you have chosen an agent:
Species:
Method:
Dose Range (in mg/kg if possible):
Route: