APPLICATION FOR USE OF ANIMAL TISSUES
Submitted to the Salisbury University Institutional Animal Care & Use Committee,
(type all responses)
T__________________
IACUC#:
The IACUC will review this request for tissues at their regularly scheduled meetings. Written IACUC approval is required prior
to implementing this request. Note: This is NOT an application for animal use.
1. TITLE OF PROJECT
.
2. PERSONNEL
Principal Investigator (including degrees)
Email Address
Position
Phone
Department
Campus Address
Primary Contact Person
Phone
3. QUALIFICATIONS
Name & Degree
Role
Permits or licenses
obtained to collect
animal tissues?
(Note: Indicate role of involved personnel as either Principal (PI), or Secondary (SI) Investigators, or technicians/assistants (T). Registering all animal
tissue in the Salisbury University Biological Inventory is required prior to IACUC approval of this protocol.
4. LOCATION: Indicate the building and room number where the procedures will be conducted.
5. CHARACTERISTICS OF THE TISSUES: This application is limited to a request for vertebrate animal tissues (e.g.,
carcasses, organs, tissues, cells and body fluids). Animals will not be euthanized for the sole purpose of deriving these tissues. No
protocol-specific antemortem manipulations will be involved in this animal tissue use. These tissues will be derived as a by-product
from animals euthanized under other IACUC-approved protocols, or from other sources (e.g., recreational use such as hunting and
fishing, slaughterhouse tissues, or from a by-product of commercial enterprise). This application is to document that appropriate
practices of acquisition, use, and disposition of animals are followed. All descriptions for the collection of animal tissues must provide
careful consideration of 1) occupational health and safety, and 2) public relations issues.
Organs/Tissues Requested:
Species:
Source*:
*Indicate from where tissues will be derived. Include the IACUC number(s) of other approved protocols if appropriate.
6.
JUSTIFICATION FOR TISSUES REQUESTED: Briefly state in lay terms the purpose (i.e., research hypothesis or
teaching objectives) of this request for tissues, and the procedures (general sequence of events) in which these tissues will be used.
7. DISPOSITION: Briefly describe the final disposition of carcasses/tissues.
8.
CERTIFICATION: This description is complete and accurate. Personnel/students are adequately trained and experienced, or
supervised to perform these procedures, and are aware of occupational health & safety practices associated with the use of animal tissues. All
vertebrate animal tissues will be acquired by lawful means, used judiciously, and disposed of appropriately.
_____________________________________________
Signature of Principal Investigator
Date
_________________________________________________________________________________________________________
Approval Signature of IACUC Chairperson
Date