UNIVERSITI TUNKU ABDUL RAHMAN
Form Title : APPLICATIONS FOR APPROVAL OF A PROJECT INVOLVING THE USE OF ANIMALS
Form Number : FM-IPSR-R&D-033
NOTE:
1.
Rev No : 0
Effective Date: 14/6/2011
Page No : 1 of 10
Complete the application in as much detail as possible referring to Universiti Tunku Abdul
Rahman Research Ethics & Code of Conduct where applicable. Attach extra paper if
necessary, and ensure that for each person involved in working with animals on this
project, a separate, signed form giving details is attached. Insufficient detail will result in the
return of the questionnaire and delay in the granting of approval.
2.
If a research grant application for this project has been submitted please attach a copy.
3.
APPLICATIONS MUST BE WORDPROCESSED OR TYPEWRITTEN AND FORWARDED TO
THE IPSR (Institute of Postgraduate Studies & Research).
Please submit with research proposal.
4.
Please direct any enquiries to the IPSR.
NAME OF PRINCIPAL INVESTIGATOR: ………………………………………….……………………..
SCHOOL/FACULTY:……………………………………………………….………………………………..
PROJECT TITLE:…………………………………………………………………………………………….
………………………………………………………………………………………………………………….
IF TEACHING PROJECT, STATE UNIT NAME AND NO: ………………………………………………
…………………………………………………………………………………………………………………..
Is a research grant application accompanying this Project Application?
YES
NO
If ‘YES’, will the project proceed regardless of the grant application outcome?
YES
NO
Received by IPSR / Secretariat, UTAR Scientific & Ethical Review Committee
Project File No: ……………………………………
PROPOSAL
1.1
Project Title (Please limit title to 15 words)
1.2
Scientific or educational aims of the projects
Date: ………………….
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UNIVERSITI TUNKU ABDUL RAHMAN
Form Title : APPLICATIONS FOR APPROVAL OF A PROJECT INVOLVING THE USE OF ANIMALS
Form Number : FM-IPSR-R&D-033
Rev No : 0
Effective Date: 14/6/2011
Page No : 2 of 10
1.3
Lay Description
1.4
Ethical Implications of the Project
1.5
Explain why techniques, which do not use animals, have been rejected as
unsuitable.
1.6
Duration (Please note ethical clearance can only be given for a maximum period of 3
years.)
Proposed commencement date _______________________________________________
Estimated duration from ___________________________ to _______________________
1.7
Investigators Involved in the Project
1.7.1
Please list the name of ALL those who will be involving in the working with live
animals on this project, and attach a separate, signed form for each person.
**NOTE. It is an offence under the Prevention of Cruelty to Animals Act for a person
who is nor approval as an investigator to proceed with a project in which animals
are involved.
1.7.2
Principal Investigator: ______________________________________
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UNIVERSITI TUNKU ABDUL RAHMAN
Form Title : APPLICATIONS FOR APPROVAL OF A PROJECT INVOLVING THE USE OF ANIMALS
Form Number : FM-IPSR-R&D-033
1.7.3
Rev No : 0
Effective Date: 14/6/2011
Page No : 3 of 10
Co-Investigators:
(a) _______________________________________________________________
Department: _________________________________ Ext: ____________
(b) _______________________________________________________________
Department: _________________________________ Ext: ____________
(c) _______________________________________________________________
Department: _________________________________ Ext: ____________
(d) _______________________________________________________________
Department: _________________________________ Ext: ____________
2.
CLASSIFICATION OF PROJECT
Please circle appropriate letter (s)
A.
B.
C.
D.
E.
F.
G.
H.
I.
Projects requiring animal to be sacrificed for the preparation of the whole animals or
tissue specimens.
Procedure carried out under anaesthesia and the animal sacrificed without regaining
consciousness.
Survival after an intervention, which causes minimal stress of short duration (e.g.
venipunture, brief restraint, and blood vessel cannulation under anaesthesia).
Survival after an intervention, which causes major or prolonged stress (e.g. major
surgery, prolonged restraint, administration of toxic or painful substances, major
behavioural modification).
Purely breeding projects.
Production of antisera.
Teaching purposes.
Fieldwork.
Other procedures – please specify.
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UNIVERSITI TUNKU ABDUL RAHMAN
Form Title : APPLICATIONS FOR APPROVAL OF A PROJECT INVOLVING THE USE OF ANIMALS
Form Number : FM-IPSR-R&D-033
3.
Rev No : 0
Effective Date: 14/6/2011
Page No : 4 of 10
ANIMALS REQUESTED
3.1 Table of Proposed/ requested Animal Usage
(NOTE: Ethical Clearance can only be given for work involving live vertebrates for a maximum period of three calendar years only.)
Species and Common Name
[PLEASE REPLACE ALL BRACKETED
TEXT, INCL. BRACKETS, WITH ANIMAL
TYPE/ NUMBER.]
Male
Female
[X]
[X]
Total No.
[enter latin name of species here]
[enter common name here]
Grand Total
(Please reproduce this page in the same format if additional species are requested. If unable to copy, please format appropriately.)
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UNIVERSITI TUNKU ABDUL RAHMAN
Form Title : APPLICATIONS FOR APPROVAL OF A PROJECT INVOLVING THE USE OF ANIMALS
Form Number : FM-IPSR-R&D-033
Rev No : 0
3.
ANIMALS (Contd.)
3.2
SOURCES AND SUPPLY OF ANIMALS
Effective Date: 14/6/2011
Page No : 5 of 10
Please indicate/delineate specifically and clearly the expected sources of animals to be
used, e.g. from which supplier, place, etc.
3.3
LOCATION OF ANIMALS
Please indicate where the animals will be housed during the experimental period.
3.4
Please indicate type (s) of environmental enrichment to be used for laboratory animals
(see Code of Practice for the care and use of animal for scientific purposes for
possible methods of enrichment).
3.5
Who will be responsible for the day-to-day care of animals (including after hours and
weekends)?
3.6
PERMITS REQUIRED If protected native species, provide details of appropriate permits
held:
Holder:
Issuing Agency:
Date of Issue:
Serial No.:
Period of Validity:
3.7
Please explain the basis for selection of the species, and outline the experimental design
to justify the number of animals to be used in the project.
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UNIVERSITI TUNKU ABDUL RAHMAN
Form Title : APPLICATIONS FOR APPROVAL OF A PROJECT INVOLVING THE USE OF ANIMALS
Form Number : FM-IPSR-R&D-033
Rev No : 0
Effective Date: 14/6/2011
Page No : 6 of 10
NOTE: Project must be design to use the minimum number of animals to achieve the
aims of the investigation.
4. EXPERIMENTAL METHODS
4.1
Procedures to be carried out on the animals
4.2
Surgical procedures to be carried out on the animals
4.3
Experience of the Principal Investigator in these procedures
4.4
Anaesthetics
YES/NO
If YES Agent: _____________________________
Dose : __________________
Route of Administration: _____________________
Duration: ________________
Observations made to ensure anaesthesia is adequate :
4.5
Neuromuscular Blocking Agents
YES/NO
If YES Agent:
Dose : _________________
___________________________
Route of Administration: ___________________
Duration: ________________
Justification for use of neuromuscular blocking agents.
4.6
Supervision during experimentation
(Detail the extent and method of supervision of animals during experimentation,
including methods to be used for assessing and preventing pain and distress).
4.7
Post-procedural care
(Detail arrangements made by the investigators for immediate and continuing postoperative and/ or post-procedural care, including details of restraint, housing and
analgesia to be used).
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UNIVERSITI TUNKU ABDUL RAHMAN
Form Title : APPLICATIONS FOR APPROVAL OF A PROJECT INVOLVING THE USE OF ANIMALS
Form Number : FM-IPSR-R&D-033
4.8
Rev No : 0
Effective Date: 14/6/2011
Page No : 7 of 10
Time animals are required to be maintained after the procedures
5. COMPLETION OF PROJECT
If animals are to be sacrificed:
(i)
state the method to be used;
(ii)
the name of the person performing euthanasia;
(iii)
the method of disposal of euthanasia animals.
(iv)
If animals are not killed, state what happen to them:
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UNIVERSITI TUNKU ABDUL RAHMAN
Form Title : APPLICATIONS FOR APPROVAL OF A PROJECT INVOLVING THE USE OF ANIMALS
Form Number : FM-IPSR-R&D-033
6.
Rev No : 0
Effective Date: 14/6/2011
Page No : 8 of 10
HAZARDOUS MATERIALS
Does the project involve exposure of live animals to any of the following:
6.1
Ionising Radiation
YES/NO
If YES, Agent
________________________________________________________________________
6.2
Carcinogen/ Teratogen
YES/NO
If YES, Agent
________________________________________________________________________
6.3
Pathogenic Organisms
YES/NO
If YES, Agent
________________________________________________________________________
6.4
Other
YES/NO
Please give details.
If YES to any above;
(i) Please indicate the health risks to Staff and/or animals involved in the project:
If YES, please complete appropriate forms.
7.
GENETIC MATERIALS
7.1
Will you be isolating the DNA
YES/NO
7.2
Will you be inserting DNA into live animals
YES/NO
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UNIVERSITI TUNKU ABDUL RAHMAN
Form Title : APPLICATIONS FOR APPROVAL OF A PROJECT INVOLVING THE USE OF ANIMALS
Form Number : FM-IPSR-R&D-033
Rev No : 0
Effective Date: 14/6/2011
8.
ANY OTHER COMMENTS
9.
DECLARATION BY PRINCIPAL INVESTIGATOR
Page No : 9 of 10
I hereby declare that I have the appropriate qualifications and experience to
perform the procedures described in this project. I am familiar with the provisions
of the UTAR Research Ethics and Code of Conduct; and accept responsibility for
the conduct of the experimental procedures detailed above; in accordance with
the requirement of the Code and any other conditions laid down by UTAR
Scientific and Ethical Review Committee.
I further declare that the procedures described in this project do not constitute
unnecessary repetition of work previously carried out by other research workers
or myself, and that each person engaged in this project has been adequately
instructed in, and is competent to perform, procedures that they are to carry out.
If they are not already skilled in the procedures, I will be responsible for seeing
that they obtain the necessary training in advance, so that each procedure on an
animal will be carried out in the most appropriate manner.
__________________________
Signature: Principal Investigator
10.
_____________________
Date
CERTIFICATION OF THE REVIEW GROUP
Authorised representative of relevant UTAR Scientific & Ethical Review
Committee
Name: (in block letters)
________________________________________________________
Signature:
______________________________________ Date: _____________________
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UNIVERSITI TUNKU ABDUL RAHMAN
Form Title : APPLICATIONS FOR APPROVAL OF A PROJECT INVOLVING THE USE OF ANIMALS
Form Number : FM-IPSR-R&D-033
11.
Rev No : 0
Effective Date: 14/6/2011
Page No : 10 of 10
DECLARATION BY DEAN
I acknowledge that it is my responsibility to ensure that all members of staff
engaged in animal experimentation comply with the conditions laid down by:
(a)
UTAR Scientific and Ethical Review Committee;
(b)
UTAR Research Ethics and Code of Conduct
Signature:
______________________________ Date: ____________________________
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