Date of Receipt:
IACUC Number:
IACUC Approval Date:
Lab Inspected Date(s):
Renewal Notice Sent:
ILLINOIS INSTITUTE OF TECHNOLOGY
INSTITUTIONAL ANIMAL CARE AND USE COMMITTEE
APPLICATION FOR ANIMAL USE PROTOCOL REVIEW
(Must be Typed)
1.
Project Title:
(Limit title to 80 spaces. Abbreviate if necessary to reduce to 80 spaces.)
2.
Principal Investigator (PI):
Department:
Work Telephone:
Fax Number:
3.
4.
5.
Mailing Address:
Email Address:
Funding Source:
Does the information in this form agree with the animal use section of the grant application? YES:
Project Period:
From:
NO:
NA:
To:
Check category of this application:
New
Previously approved project (IACUC #
) being submitted with significant changes to another funding agency or
resubmitted to the same agency. Section(s) changed:
Three year resubmission of IACUC #
There have been no significant changes
Significant changes have been made to the following sections:
6.
7.
Will any aspect of this study or animal husbandry be conducted at another institution?
Yes
No
If yes, where?
Was the proposal approved by their IACUC? Yes
If yes, please attach their approval notification. If pending, please indicate:
No
Other individuals authorized to handle animals used in this project and make decisions regarding health status and treatments:
Name:
Department:
Work Telephone:
Mailing Address:
E-mail Address:
Name:
Department:
Work Telephone:
Mailing Address:
E-mail Address:
Name:
Department:
Work Telephone:
Mailing Address:
E-mail Address:
Name:
Department:
Work Telephone:
Mailing Address:
E-mail Address:
IACUC 1-02A
1
Confidential
8.
IN NON-TECHNICAL LANGUAGE THAT THE LAYPERSON, NON-SCIENTIST COMMITTEE MEMBERS CAN
UNDERSTAND (e.g. use heart instead of cardiac, chemical instead of leukotriene, etc.) summarize the purpose of this project
including a description of the probable benefits of this work. An average 7th grade student should be able to understand the
purpose of the proposed project without using a medical dictionary. Inadequate lay descriptions will result in delayed
IACUC application review and/or this application will be returned with a request for revisions.
9.
List the specific aims and objectives of this project in technical terms. Provide sufficient information so that the scientists on the
IACUC can understand what questions are to be answered and how you propose to answer them. If the same information has
already been listed on one page of your grant application, that page may be substituted and attached to the IACUC application.
Please limit your response to this item to one page.
10.
Species and number of animals required for project period:
Species*
Strain**
Total
Maximum #
At One Time
a.
b.
c.
d.
e.
f.
*Use common names. **Give strain names for mice, rats, hamsters, guinea pigs and rabbits.
11.
Humane use categorization for each species listed above:
Species to be used***
(common names)
A
Little or no pain or
distress
B
Pain or distress with
appropriate anesthetics,
analgesics, or
tranquilizers
C
Pain or distress without
appropriate anesthetics,
analgesics, or
tranquilizers
a.
b.
c.
d.
e.
f.
***List by species in the same order as in Question #10. Columns A, B, and C are the number of animals that will be used in
each category. The categories are described in the instructions for completing this application.
12.
Number of animals: federal guidelines state that you must justify the number of animals you listed in Question #10.
Whenever possible, the number of animals requested should be justified statistically. List, preferably in table form, all the
IACUC 1-02A
2
Confidential
control and experimental groups, and indicate the number of animals in each group. I have consulted a biostatistician in the
planning of this project: yes______ no_______.
13.
a.
Describe how the results of this study are to be measured and/or evaluated. List all statistical analyses to be used for
any data obtained from the animals and/or animal tissues (cells). When applying statistical analysis, it is critical that
the appropriate tests be selected prior to initiating the study. If you have a question concerning the appropriate test,
please consult a statistician as also suggested in #12. (Attach additional page if necessary.)
b.
Are mathematical models, computer simulation or in vitro biological systems acceptable alternatives to the use of
animals in this project? (Explain. Attach additional page if necessary.)
YES ____
NO _____
14.
c.
Justify the use of each species of animal you listed in #10. Describe the biological characteristics that are essential to
the proposed study. Explain why species lower on the phylogenetic scale cannot be used. (Attach additional page if
necessary.).
d.
Describe the experimental endpoint(s); when all experimental animals will be terminated. If an animal’s
‘moribund’ condition is to be used to determine when animals are to be euthanatized, define or describe the
parameters that will be used to determine the ‘moribund condition’.
Special Requirements / Animal Housing:
a.
Are special animals required? Yes
b.
Where will animals be housed (specific location)? If animals are not going to be housed in a previously approved
animal care facility, describe the housing and its adequacy for the care of the animals.
c.
Is special housing required? Yes
d.
Where will procedures be performed on the animals? (e.g. your lab, etc)
IACUC 1-02A
No
No
(If yes, state requirements.)
(If yes, describe.)
3
Confidential
Building:
e.
15.
Room:
Are there other special requirements for animal maintenance? Yes
No
(If yes, describe.)
Use of potentially hazardous compounds/organisms (if none, so state):
a.
Answer for each of the following types of hazards.
Yes No
Specify Agent
Submission Date
Approval Date**
Carcinogens
Biohazards, including infectious agents *
Recombinant DNA
Chemical Hazards
Radioisotopes
* The use of tissues and/or fluids from humans may constitute a possible biohazard, and as such, the use of these
requires a yes answer and should be explained with the appropriate safety measures to be taken.
**If biohazards or recombinant DNA are to be utilized, it is required that an Institutional Biosafety Committee
(IBC) application has been submitted (or approved). If radioisotopes are to be utilized, it is required that a
Radiation Safety Officer has been informed and approved the activity.
b.
16.
If the answer to any of 15.a. is yes, describe safety measures taken and disposal protocols used. Also indicate in what
rooms the substances will be administered and what facility will be used for housing the animals.
Experimental Techniques:
a.
For each species, describe the animal use procedures to be performed (include surgery) in the order in which they will
be performed. Include time frame and intervals for the sequence of procedures, volumes of agents to be injected and
volumes of blood to be removed. If the procedures are to be performed after the animals are euthanatized, so state.
(Attach additional page if necessary.)
b.
Describe any possible adverse effects of this study on the animal's well being. Include any that may be perceived by a
layperson as causing pain or distress, e.g. restraint, illness, seizures. Procedures that cause pain in humans are
interpreted to cause pain in animals. Analgesics are recommended for use in all post-operative animals. Include the
use of any pain or distress relieving drugs. If such drugs are not necessary or cannot be used, explain. (Attach
additional page if necessary.)
IACUC 1-02A
4
Confidential
16.
c.
If not included in 16.a., describe the surgical procedures, use of sterile techniques, sutures, pre and post operative
medications, and post operative monitoring plan.
d.
Type of surgery: (Check all that apply.)
Non-Survival (The animal is euthanatized before awakening from anesthesia.)
Survival (The animal is allowed to recover from anesthesia.)
Multiple
(This pertains to more than one surgical procedure performed on an individual animal. Attach
additional page with justification for multiple major survival surgery.)
e.
In the table below, list tranquilizers, analgesics, and anesthetics used. Note that all drugs used for ANY purpose on
animals MUST be used within the manufacturer’s expiration date or recommended shelf life. The researcher and staff
are responsible to know that information for all drugs used.
Species
Drug
Dose
Volume
Route
Frequency
Purpose
a.
b.
c.
d.
e.
f.
Describe safety procedures for handling gas anesthetics
f.
If not included in the response to Question 15.a., specify all test substance(s), agent(s), dose(s), and route(s) of
administration to be used.
Species
Drug
Dose
Volume
Route
Frequency
Purpose
a.
b.
c.
d.
e.
f.
16.
g.
Euthanasia. Identify the method(s) used by species. If drugs are to be used, include dose and route of administration.
Method(s) must conform with those recommended by the AVMA Panel on Euthanasia or provide justification.
Cervical Dislocation under sedation or light anesthesia
Decapitation under sedation or light anesthesia (Describe technique)
IACUC 1-02A
5
Confidential
Carbon Dioxide Inhalation
Exsanguination Under Anesthesia
Ether
Injection (Describe below with drug name, dose, and route of administration; KCL must be administered under
general anesthesia, please indicate).
Species
Drug
Dose
Route
a.
b.
c.
d.
e.
f.
Other: (Describe)
h.
17.
Describe how and by whom the animals will be monitored. Daily monitoring is recommended. Indicate what the
animals will be monitored for and the action to ensure that there is no unnecessary suffering. If animals become sick or
moribund during the experiment, will they be euthanatized at that time?
Personnel: Give the names of all individuals who will be directly involved in the animal use, including students, residents,
interns, etc., even if temporary. Specify the type and length of training or experience using this species and with these
procedures that qualifies these individuals to perform the procedures indicated below. (DEGREES OR OTHER
CREDENTIALS ALONE ARE NOT SUFFICIENT AS QUALIFICATIONS.) If to be performed by a technician to be
named later, please indicate this and how you will ensure that this person is properly trained. If an individual has no experience,
please so indicate. Please note: The principal investigator MUST ensure that all individuals have proper training before work
begins. The principal investigator MUST contact the campus veterinarian and/or the IACUC office to arrange training if needed
for staff. The principal investigator MUST notify the IACUC office when new individuals join a research team.
a.
Who will perform the experimental or test procedures (non-surgical)? (Name and qualifications.)
b.
Who will perform the surgical procedures? (Name and qualifications.)
c.
Who from your lab will provide the daily monitoring of the animal? (Name and qualifications.)
d.
Who will provide the post surgical care and monitoring? (Name and qualifications.)
IACUC 1-02A
6
Confidential
18. Will any of the procedures performed during this study either inflict slight pain or cause distress in the animals that is more than
momentary and will not be relieved by anesthesia, analgesia or tranquilization? (brief restraint, injections, or bloodwithdrawals are exempt from this question)
NO _____
YES _____ If Yes, the USDA requires that for each painful procedure, you make a good faith effort to find alternatives that
might cause less pain or distress. Please complete sections a-e below with a narrative description of the methods and sources
used to determine that there are no alternatives to the painful procedure(s).
a.
Alternatives that might cause less pain or distress: I have consulted
the following databases for my alternatives search:
b.
Date of the search:
c.
Years covered by the search:
d.
Key words used for the search:
e.
Other Sources Consulted :
Medline
Biological Abstracts
Index Medicus
Animal Welfare Information Center
Others:
19.
Search for alternatives to the use of animals: Please justify the use of live animals for this protocol, indicating why the use of
the animals will benefit human or animal health and well-being.
20.
The attending veterinarian or his or her designee must be consulted in planning this study. Give the name of the individual only
if he(she) has been consulted on this specific project:
21.
Occupational Health and Safety (OHS) Responsibilities: Animals can sometimes cause diseases to humans. These diseases
are called zoonoses. If you have questions about whether you or your staff need to have an immunization to protect against
zoonoses, you should consult with your personal physician or with the campus veterinarian. The university will reimburse the
cost of your immunizations. Training is available from the campus veterinarian to help you recognize zoonoses. You are
responsible for surveillance of your staff. Should you suspect a zoonotic infection, you should contact the campus veterinarian,
campus occupational health and safety office, and IACUC Chair.
I acknowledge these OHS responsibilities (initial here): ________
22.
SIGNATURES AND ACKNOWLEDGEMENTS: I acknowledge responsibility for this project. I affirm that I will obtain
Institutional Animal Care and Use Committee (IACUC) approval prior to significant changes in the protocol. I affirm that
students, staff and faculty working with the animals as part of this project are qualified or will be trained to conduct the project
in a humane and scientific manner, in accordance with, as applicable, U.S. Department of Agriculture Animal Welfare
regulations (Code of Federal Regulations, Title 9, Chapter 1, Subchapter A, Parts 1, 2, 3); the Public Health Service Policy on
Humane Care and Use of Laboratory Animals, the National Research Council Guide for the Care and Use of Laboratory
Animals, and the policies established by IIT. I certify that I will ensure that all drugs used on animals in this study will be within
IACUC 1-02A
7
Confidential
expiration date. I affirm that the use of these animals will be in accordance with all other applicable federal regulations, PHS
policy, and institutional policies. I also affirm that this project does not unnecessarily duplicate previous experiments.
Signature of Principal Investigator:____________________________________________
Date:
Signature of Academic Unit Head:____________________________________________
Date:
IACUC 1-02A
8
Confidential