University of Washington
Institutional Animal Care and Use Committee
Protocol # _______________
Request for Significant Change to Animal Use Protocol
*** Please type-handwritten forms will be returned ***
Submit to: IACUC, Box 357160 or via email at OAW.
IACUC Protocol PI: ________________________________________________________________________
Department: ___________________________________ Faculty Title: ______________________________
Protocol Title: _____________________________________________________________________________
Project Dates: ___________ to ___________ Funding Source(s): ____________________________________
A list of examples of Significant Changes requiring approval prior to implementation is available at here.
INSTRUCTIONS:
 NEW PERSONNEL: Do not use this form. Submit a “Request for Addition of New Personnel” form.
 INCREASE IN NUMBER OF ANIMALS APPROVED: attach:
1. Rationale, as it relates to the approved protocol, for the need to increase the number of animals.
2. Scientific rationale for the actual number of additional animals requested.
 CHANGES IN ANIMAL USE PROCEDURES: attach:
1. Rationale for the changes, as they relate to the approved protocol.
2. Description of the change(s), being careful to include all required information (use additional pages as
needed). Please refer to a Project Review Form for New Projects, to determine the required information.
 ADDING ANOTHER SPECIES: attach
1. Rationale for the need to add another species.
2. Answers to all questions in sections F through N of a Project Review Form for new projects.
3. Number of animals requested.
4. Scientific rationale for the number of animals requested.
5. Complete answers to any relevant procedures questions as requested on a Project Review Form for new
projects.
Certification Statement
I certify that the original Project Review Form in conjunction with this Significant Change, accurately describes all aspects of the
proposed animal usage. I further certify that the use is not unnecessarily duplicative. I accept responsibility that all personnel working
on the project will adhere to the regulations regarding the humane treatment of laboratory animals and will receive proper training as
required by the ACC. I will obtain approval prior to instituting any other significant changes in the project. I understand that the
approval is not final until I receive notification of such in writing, and that the ACC can require changes to the protocol. I understand
that approval of projects is for a maximum of one year from the date of ACC approval of the original submission, and that approval of
the significant changes submitted on this form will not change the date of the annual renewal.
______________________________________________
Signature (PI or other protocol personnel if PI unavailable)
___________________________________
Date
(ANIMAL CARE COMMITTEE USE ONLY - DO NOT WRITE BELOW THIS LINE)
Animal Use Categorization: ________________________
CTC: ____________________________
Comments:_________________________________________________________________________________
__________________________________________________________________________________________
Data entry & Designated Reviewer: ____________________ Review Date: ______________________________
Date Approved by IACUC: ________________________ (Renewal date of protocol is not changed.) Revised 2012