IACUC COVER PAGE
Place a check next to the procedures you will be performing. Enter the total number of animals
in each category as well as the total number in multiple categories. Complete a separate
“Checklist” for each species. For observational studies/field trips that do not materially alter
animal behavior IACUC approval may not be necessary (see below).
# Used per year
1.
CATEGORY B – Teaching and/or research or tests that involve breeding or housing of
animals only
Breeding colony
Housing ONLY (no other procedures)
2.
CATEGORY C – Teaching and/or research experiments that do not involve more than
momentary pain and/or distress or require the use of pain relieving drugs.
Alert animals (behavioral observation or brief restraint
Anesthetize and release for non-invasive procedures (ie. Imaging, bandage change)
Change in environmental parameters (light cycle, room temperature, etc.)
Chemical carcinogens (ie. BrdU)
Euthanasia with or without tissue/organ harvest
Forced exercise
Irradiation
Microbiological agents
Westfield State University
Institutional Animal Care and Use Committee (IACUC)
2013
Page 1
Non-surgical collection of body fluids (blood, urine, etc.)
Radioisotopes
Simple injections (IP, IV, etc.)
Use as a parasitic host
3.
CATEGORY D – Teaching and/or research experiments or tests that will involve pain
and/or distress and for which appropriate anesthetic, analgesic or tranquilizing drugs
will be used.
Anesthetize and release for non-surgical painful procedures (ie. retro-orbital
bleeds)
Antibody production: polyclonal (non-ascites, no footpad)
Antibody production: ascites
Burns
Controlled drugs or substances (as test material, ie. cocaine)
Toxic substances (ie. streptozoticin, MPTP, cisplatin, doxycycline.
Electric shock
Food or water deprivation other than pre-surgical fasting
Footpad injections (antibody production or microorganism)
Gavage
Tail biopsy for genotyping
Introduction of illness (including the administration of toxins, microbiological
agents, clinical transgenic phenotypes)
Westfield State University
Institutional Animal Care and Use Committee (IACUC)
2013
Page 2
Lavage
Multiple survival surgery
MAJOR
MINOR
Survival surgery
MAJOR
MINOR
Physical trauma
Transgenic mouse production (embryo manipulations to produce novel strains, etc.
Tumor induction or implantation
Unusual or prolonged restraint (anything other than standard, ie. pie chamber)
Use of paralytic agents
4.
CATEGORY E – Teaching and/or research experiments, surgery or tests that involve
PAIN and/or DISTRESS, and for which appropriate anesthetic, analgesics or
tranquilizing drugs are NOT used because they would adversely affect the results or
interpretation of data.
Any lethal dose studies*
Death-as-an-endpoint* studies
Noxious stimuli from which there is no escape
Pain study
Withholding of post-operative analgesia for any surgical procedure
Westfield State University
Institutional Animal Care and Use Committee (IACUC)
2013
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OBSERVATIONAL STUDIES/FIELD TRIPS THAT DO NOT INVOLVE A MATERIAL
ALTERATION IN ANIMAL BEHAVIOR (I.E., TRAPPING, SIGNIFICANT
DISTURBANCE TO NESTING, MATING, FEEDING ETC.). SUCH STUDIES DO NOT
REQUIRE FORMAL IACUC SUBMISSION. AN APPROPRIATE STATEMENT OF NO
MATERIAL AFFECT TO ANIMAL BEHAVIOR SHOULD BE KEPT ON FILE (WITH
SIGNATURE OF THE CHAIR) IN THE INSTRUCTOR’S DEPARTMENT. PLEASE
ATTACH THIS COVER SHEET TO SUCH STATEMENTS.
IF YOU CHECKED BOXES IN GROUP 1 (CAT B) OR GROUP 2 (CAT C) ONLY YOU
MAY COMPLETE AND SUBMIT THE SHORT FORM AEP.
IF YOU CHECKED BOXES IN GROUP 3 (CAT D). GROUP 4 (CAT E) OR IF YOU ARE
SUBMITTING FEDERAL GRANT PLEASE COMPLETE AND SUBMIT THE LONG
FORM AEP.
PI must print and sign below:
P.I. Name
P.I. Signature
Date
Thank You!
Westfield State University
Institutional Animal Care and Use Committee (IACUC)
2013
Page 4
Westfield State University Institutional Animal Care and Use Committee (IACUC)
http://www.westfield.ma.edu/IRB-IACUC/
ANIMAL EXPERIMENTATION PROTOCOL
Principal Investigator:
Westfield State University Title:
If you do not have a Westfield State University faculty appointment, provide the name of a
sponsor such appointment and include their title.
Department:
Address:
WSU Telephone:
E-Mail Address:
Contact Person:
Phone & Email
Protocol Title:
Funding Source(s)
and Grant Title(s):
The undersigned individuals accept responsibility for compliance with all federal and nonfederal regulations and laws pertaining to humane care of animals/used research.
Principal Investigator’s signature:
Date:
Sponsor’s Signature:
Date:
(Required if PI is not a Faculty rank)
Department Head Signature:
Date:
Date:
Department Head Print Name
Legibly:
This proposal has been reviewed and approved by the Westfield State University IACUC
WSU IACUC Primary Reviewer:
______________________________
A MESSAGE FROM THE COMMITTEE
Please Read and Sign This Page to Avoid Rejection of Your Protocol
Westfield State University
Institutional Animal Care and Use Committee (IACUC)
2013
Date:
________
Date:
________
Page 5
The institutional Animal Care and Use Committee (IACUC) oversees all WSU
research and instruction that involves vertebrate animals, in order to ensure that
the highest ethical and animal welfare standards are met and that the University
is in compliance with the requirements of the Animal Welfare Act and
Regulations, the NIH Guide for the care and Use of Laboratory Animals, and the
Public Health Service Policy on the Humane Care and Use of Laboratory Animals.
IACUC approval must be obtained before the start of any project using live
vertebrates that involves invasive procedures, potential harm to the animals, or
materially alters the animals’ behavior. IACUC approval must also be obtained
before the start of any field project using live vertebrates that involves invasive
procedures, potential harm to the animals, or materially alters the animals”
behavior. This applies to teaching (including classroom
demonstration/presentation of animals) and research projects that are conducted
through or on the WSU campus, associated with any degree program at WSU, or
financed by any internal or external funding administered by WSU.
The Committee members today include scientists, veterinarians, and lay
representatives. This Committee is committed to the continued use of animals in
research within the constraints of humane treatment as viewed by society. To
justify approval of procedures, the Committee must have adequate written
information regarding the steps taken to assure humane treatment of animals.
Present your material clearly and concisely. Lay members of the Committee
must be able to understand this protocol.
I have read the above in full and agree to adhere to the guidelines established by
the USDA, the PHS, AAALAC and the Westfield State University IACUC. By signing
this protocol form, I confirm that this information is correct and accurately
reflects the information in the specific grant application(s) of fellowships cited on
the Face Page of this protocol form.
Principal Investigator:
Date:
Thank you for your cooperation.
Westfield State University
Institutional Animal Care and Use Committee (IACUC)
2013
Page 6
I.
MANDATORY RISK DISCLOSURE
**MUST CHECK X ALL THAT APPLY**
Check:
Procedures:
Identify specific agent(s):
Route(s):
Chemical Carcinogen(s)
Controlled Substance(s) DEA schedule II-V
Toxic substance(s)
Radioisotope (License#)
Microbiological Agent(s)(COMS #)
Human cell line(s) or tissue(s) (COM#)
Anesthetics and/or Analgesics
Non-human animal cell line(s) or tissue(s)
Human embryonic stem cells (hESC)
Other (must specify):
X
NONE OF THE ABOVE: This box MUST be checked if none of the above agents apply to
your work described in this protocol. By checking this box & signing below YOU ARE
EMPHATICALLY STATING THAT YOU ARE NOT USING ANY OF THE ABOVE IN RESEARCH
ANIMALS.
PI must print and sign below:
PI Name:
PI Signature:
Westfield State University
Institutional Animal Care and Use Committee (IACUC)
2013
Date:
Page 7
II. SHORT FORM SECTIONS
A. PROCEDURES
Briefly describe the procedures to be conducted on animals as well as the aims and
significance of your experiments. You do not need to include in vitro work done on
tissue taken from the animal. You must use language that can be readily understood
by investigators not familiar with your specific field of research and by nonscientists. If a particular section is not applicable please indicate this by inserting
“n/a” in the section heading.
1.
Aims and Significance:
2. Procedures and manipulations (in lay terms, provide a short description of all
animal procedures and manipulations (including changes in light cycle, alteration
of feeding, etc.)
B. PERSONNEL
Will the principal investigator perform the procedure?
Yes
No
 Provide the name(s), title(s) and qualifications for each person, including the PI,
who will work with the animals.
 Include the number of years of experience working with the species listed above.
 If the person needs to be trained, indicate who will do the training.
Name, Title, Job Classification (research fellow, research technician, co-PI, lab manager etc.),
Qualifications, Years Experience with species/procedures in this protocol, Trainer, phone number,
email.
Title/Job
Name
Qualification/Experience Phone
Email
Classification
1.
2.
3.
4.
Westfield State University
Institutional Animal Care and Use Committee (IACUC)
2013
Page 8
C.
HOUSING/PROCEDURE LOCATION
C.1 Where will your animals be housed?
Species
Building
Room #
a.
b.
c.
C.2
Provide the area(s) where your animal procedures will be performed,
including euthanasia.
Planned Procedure Time in this area if not
Species
Building
Room #
in this area
an HMS ARCM area
a.
b.
c.
D.
EUTHANASIA
How and when will the animals be euthanized?
**Cervical dislocation and guillotining without anesthesia are no longer acceptable
unless scientifically justified and approved by the Committee. Any deviation from
the AMVA Guidelines must be justified below
Dry Ice is NOT AN ACCEPTABLE METHOD of euthanasia under any circumstances. If
you using CO2 as a means of euthanasia, you MUST use a second physical means to
ensure death (e.g., bilaterial thoracotomy, exsanguination, or harvest of an essential
organ, etc.)
D.1
Method of euthanasia for each species (include justification, if necessary):
Species
Method, Justification and duration of survival until euthanasia
(give best estimate for long term studies)
a.
b.
c.
Westfield State University
Institutional Animal Care and Use Committee (IACUC)
2013
Page 9
E. EXPERIMENTS INVOLVING BEHAVIORAL CONTROLS, RESTRAINT OR ANALYSIS OF
BEHAVIOR ON ALERT ANIMALS.
Will your study involve experiments on alert animals or involve
behavioral control, restraint, or analysis of behavior?
YES
NO
If “YES”, complete the following:
1. If behavioral control, with use of food or water deprivation, state
the duration of food or water deprivation and means to ensure
the welfare of the animal:
2. If behavioral control with psychotropic drugs and withdrawal,
specify duration, monitoring plan during withdrawal and means
to ensure the welfare of the animal:
3. a. Describe restraint method and duration:
b.
If unusual or prolonged restraint, state means to ensure the
welfare of the animal while in the restraint.
NO
Deprivation
NO
Drugs
NO
Restraint
F. DIET OR ENVIRONMENTAL CHANGES
Will you study any of the following effects of environmental
changes or diet (DOES NOT) include deprivation to prepare for
surgery)?
YES
NO
YES
1.
Food deprivation?
2.
Water deprivation?
3.
Temperature changes?
4.
Changes in the light cycle?
5.
Other diets or changes (specify):
NO
If “YES” to any of the above, complete the following:
Westfield State University
Institutional Animal Care and Use Committee (IACUC)
2013
Page 10
6.i.
Brief description of the experiment:
6.ii
Effect on the animal’s health – be specific:
6.iii. Duration of the experiment:
6.iv. Specify duration of water or food deprivation and provide justification:
6.v.
Describe the specific observation schedule and identify the personnel who will
monitor the animals:
6.vi. Specifiy your monitoring criteria:
Westfield State University
Institutional Animal Care and Use Committee (IACUC)
2013
Page 11
G. JUSTIFICATION FOR THE USE OF ANIMALS
1)
Why animals are needed for this study (i.e: Could the same information be
obtained by experiments using tissue culture or computer models?)
2)
Justify choice of each species:
3)
Justify the number of animals to be used (you must convince the Committee
that the number of animals is appropriate to the work being proposed.
4)
Discuss your strategy to reduce the number of animals and to minimize pain and
distress to your animals (examples include: earlier euthanasia, decreasing the
number of time points, changing the methods to those that are less invasive):
Westfield State University
Institutional Animal Care and Use Committee (IACUC)
2013
Page 12
H.
MINIMIZATION OF DISCOMFORT, PAIN AND DISTRESS
Summarize your procedures as follows to avoid or minimize any discomfort, pain or
distress the animals may experience.
1.
Observation schedule:
2.
Criteria for determination of pain and distress:
3.
Action taken to relieve pain and distress:
I.
PROTOCOL PERSONNEL SIGNATURE PAGE
The investigator and all research staff members are required to sign this form, thus
certifying that they: (1) have read the protocol; (2) are familiar with all of its
requirements relating to their activities; (3) have had the opportunity to ask questions
about it; and (4) understand that all animal-related activities not described in the
protocol are prohibited in the absence of an amendment approved by the IACUC.
Name
Signature
1.
2.
3.
4.
5.
6.
PI must print and sign below:
P.I. NAME
P.I. Signature
Date
THANK YOU!
Westfield State University
Institutional Animal Care and Use Committee (IACUC)
2013
Page 13