ࡱ> fhey g*bjbj 1h{{@"BBBVVV8<VK(" '''''''$*-f'B!"!!'(!$!$!$!8'!$!'!$!$V&@*N'DIM"F'('(0K(B' -"$-N'-BN'h>. ,!$Z $~ #''#jK(!!!!- : APPLICATION FOR APPROVAL OF THE USE OF VERTEBRATE ANIMALS IN RESEARCH THE UNIVERSITY OF MASSACHUSETTS DARTMOUTH - Animal Care and Use Committee All items must be completed. Incomplete applications will be returned. If specific items are not pertinent to the proposal, indicate by N/A (Not Applicable) Rev. 2/21/06 Funding: (State Source) Protocol Number:NIH Grant No:  Previous Protocol Number:UMD:  Date Submitted: Other:  Date Approved:  Project Title: Principal Investigator: Project Period: Department: Telephone: Home Telephone: Purpose of Study: (Be specific): Animal Species: Number : Source: Total animals needed for actual experimental procedures:__________________ Total Number of animals to be housed at any one time:______________ Will animals be bred for this protocol: Yes  FORMCHECKBOX  No  FORMCHECKBOX  If Yes: Total animals to be maintained in order to provide experimental animals: Timetable for when the animals will be needed: _____________________________________________________________________________________ 1 = negligible ____ Distress/Discomfort/Pain Level is: 2 = avoided by drugs ____ 3 = short term discomfort/pain ____ 4 = long term discomfort/pain ____ 5 = extreme discomfort/pain ____ Will this study involve: (check YES or NO) Procedures/methods Biohazard Materials (*requires Yes No attached approval from Institutional Immunological methods: _____ _____ Biosafety committee) Surgical procedures: _____ _____ *Yes No Microbial agents: _____ _____ Radioactive isotopes: _____ _____ Hazardous Chemical: _____ _____ Biohazardous materials: _____ ____ Provide explanation for any Yes responses in Item 4, Experimental Design. 1. RATIONALE: a) for the use of an animal model (rather than in vitro or human models): b) for the use of this species: c) for the use of the requested number of animals: d) briefly comment on potential benefits to individuals or society which may result from this study: 2. EXPERIMENTAL DESIGN: Provide a full description of the experiment (in lay terms, if possible). Include number of animals in each group: Does this project involve transgenic or otherwise compromised animals?YesNo If YES, describe any phenotypic abnormalities the animals may display. Does this project involve breeding transgenic or otherwise compromisedYesNo If YES, what percentage of the litter carry the mutation of interest? % What will the remaining animals be used for? 3. Will these studies require: (check YES or NO) Yes No a) prolonged (>18 hrs.) deprivation of food and/or water? ____ _____ b) feeding of dietary supplements, synthetic or deficient diets? ____ _____ c) addition of natural or synthetic substances to drinking water? ____ _____ d) increased animal density per cage? ____ _____ e) decreased frequency of cage changing? ____ _____ f) other: Explain all Yes answers. If (a) is checked submit complete protocol for deprivation including schedule and system for monitoring the animals. List all information if (f) is checked. 4) Explain the methods to be used and the rationale for using any procedures indicated on bottom of page 1: 5) Identify and describe in detail all survival surgery procedures. State the order and frequency they will be performed: 6) If any levels 2-5 involving Pain or Distress on page 1 were indicated: Describe the procedure for relieving the possible pain/distress produced. Include specific drugs. Route of administration, and justification. Indicate source(s) consulted (consultation with experts, literature searches, etc.) to determine if there are alternative procedures that would reduce the pain/distress associated with the experimental procedures. If a literature search was conducted, indicate the database searched and the specific keywords used in the search. 7) Describe any restraint system required for this study (i.e., collar, vest, harness, sling, etc.): 8) Describe all non-surgical procedures, other than routine care, to be used in this study. Include order and frequency: 9) Specify the method of euthanasia to be used at the conclusion of the study: 10) Describe the tissue or fluid harvesting procedures to be used: 11) List the names and telephone numbers of all staff responsible for the care and upkeep of the animals. Indicate individuals performing surgery, if proposed: What is the relevant training and background of these individuals? Please be specific: Will students (undergraduate, graduate, postdoctoral) be involved in this project? Yes ____ No ____ If YES, describe their relevant experience in ANIMAL care and handling and their specific roles in the project. (Note: The PI is directly responsible for the supervision of students at all times). Name of Participant Completed UMD Training Program Date of Training YesNoYesNo 12) Describe the process used to determine that the proposed activities do not unnecessarily duplicate previous studies. (State database names and dates of last search). Please be specific. _______________________________________________________________________________________ I, the undersigned, accept responsibility for assuring that this study will be conducted in accordance with the Animal Welfare Act, the Guide for the Care and Use of Laboratory Animals, applicable Federal and State laws, and the regulations, Standard Operating Procedures, and Policies of the Institutional Animal Care and Use Committee (IACUC) of The University of logo-Dartmouth with regard to humane care and protection of the laboratory animals involved in the study. I, the undersigned, accept responsibility for assuring that this study does not unnecessarily duplicate previous studies as determined by item 12 of this protocol. I agree to request, in writing, and obtain written approval from the Institutional Animal Care and Use Committee prior to making any significant changes in this protocol (e.g. personnel, surgical modifications; etc.). I also agree to promptly notify the IACUC, in writing, of any emergent problems which may arise in the course of this study, including unexpected adverse side effects. ______________________________________ ___________________________ Signature of Principal Investigator Date Approved by the Institutional Animal Care and Use Committee, The University of logo-Dartmouth on: ______________________________________ ___________________________ Signature of Committee Chairman Date       PAGE \*ARABIC 1 FoQ U \ h i x z   # ' = A Ÿ}reUHD}}h*}hL 59CJOJQJh*}59CJOJQJ\aJh*}5CJOJQJ\h*}5CJOJQJh*}9CJOJQJh*}59CJOJQJh*}5CJOJQJh*}9CJOJQJh*}59CJOJQJh 59CJOJQJh*}9OJQJh*}59CJOJQJh*}9CJOJQJ h*}9 hq9h*}9CJ\ h*}9\Fx y z Mkd$$If4p0&Y44 xasf4$If$a$$a$ %  _Mkd$$If4h0&Y44 xasf4$IfMkdh$$If4h0&Y44 xasf4   ' A e $a$ $$dNa$$d,a$ $&dPa$Mkd8$$If40&Y44 xasf4A O W a e n w J Y ~ 3 B Q R  C 薩胩vvrm h*}>*h*}h*}9CJOJQJo($jh*}9CJOJQJU$jh*}9CJOJQJUjh*}9CJOJQJU&h*}9CJOJQJehrh*}59>*CJOJQJh*}5>*CJOJQJh*}9CJOJQJh*}59CJOJQJ( J  S  ;9)$ 5 !$`'0*-/2p5@8;=@CPF$dNa$ $ 5 !$`'0*-/2p5@8;=@CPFa$ 8^8`8^8 & F ) )s^sC :;]t$89]w2WXݺraaTh>?59CJOJQJ!hQhQ59>*CJOJQJhQh*}59CJOJQJ!hQhQ59>*CJOJQJhQ59CJOJQJh*}59CJOJQJh*}59CJOJQJhQ59CJOJQJh*}9CJOJQJhQ9CJOJQJh*}9CJOJQJh*}9CJOJQJh*}9>*CJOJQJ Y<*]^_`,$ ;ZZ !$`'0*-/2p5@8;=@CPF&dPa$#$ ;ZZ !$`'0*-/2p5@8;=@CPFa$)$ 5 !$`'0*-/2p5@8;=@CPF$dNa$XYZ~/;<= $-x  ]_ƹުލӍރykh*}569CJOJQJh CJOJQJhQCJOJQJh 9CJOJQJ"hQhQ59CJOJQJaJhQ59CJOJQJaJhQ9CJOJQJaJh>?59CJOJQJh*}9CJOJQJhQ9CJOJQJh*}CJOJQJh*}59CJOJQJ'`n~`````````1$ V<Pp@ P !$`'0*-/2p5@8;=@CPFa$2$ Y<Pp@ P !$`'0*-/2p5@8;=@CPFa$;$ Y<Pp@ P !$`'0*-/2p5@8;=@CPF$dNa$ ^gIJMN25j Z[fl %06ŸŸŸŸŸŭŗŗŗŢŊŗh m9>*CJOJQJh m9CJOJQJh*}9CJOJQJh m9CJOJQJh*}9>*CJOJQJh*}9CJOJQJh*}59CJOJQJh*}59CJOJQJh*}CJOJQJh*}9CJOJQJ6bcdefg9$ V<Pp@ P !$`'0*-/2p5@8;=@CPF$dNa$1$ V<Pp@ P !$`'0*-/2p5@8;=@CPFa$EIJMNOikd$$If4hrs "$&]###44 zaxf4 $If]$IfO$If1$ V<Pp@ P !$`'0*-/2p5@8;=@CPFa$;yH1$ V<Pp@ P !$`'0*-/2p5@8;=@CPFa$kd$$If4hrn "$&]###44 zasf4;jklm ]];"$ 8Z| !"$`'0*-/2p5@8;=@CPFa$;$ Y<Pp@ Pb"$`'0*-/2p5@8;=@CPF$dNa$2$ Y<Pp@ Pb"$`'0*-/2p5@8;=@CPFa$4$ V<Pp@ P !$`'0*-/2p5@8;=@CPFa$gd  l6<z>$ P|d V8!H$~'**,/2p5@8;=@CPFD$dN^`Da$#$ ;Z| !"$`'0*-/2p5@8;=@CPFa$"$ 8Z| !"$`'0*-/2p5@8;=@CPFa$ 9$U[13 !!!!!"!"#""$$&&&&&',(2(3(?*@*A*C*D*F*Ǽټټٗٗټټ}}uquqh>qjh>qUh}99CJOJQJhzd9CJOJQJh*}hzd59CJOJQJh$}9CJOJQJh*}9>*CJOJQJh*}9CJOJQJ h*}5h$}59CJOJQJh*}59CJOJQJh*}9CJOJQJh*}59>*CJOJQJ,<=>?@ABCDE`>$ P|d V8!H$~'**,/2p5@8;=@CPFD$dN^`Da$2$ P|d V8!H$~'**,/2p5@8;=@CPF^a$.$ P|d V8!H$~'**,/2p5@8;=@CPFa$ K9$ V|8d V8!H$~'**,/2p5@8;=@CPF|^`|a$ ! & F |8>^>>$ P|d V8!H$~'**,/2p5@8;=@CPFD$dN^`Da$.$ P|d V8!H$~'**,/2p5@8;=@CPFa$fffffff.$ Pj \>!N$'0*,/2v5F8;=@CVFa$1$ & F P \DN!6$&),v/(24 8:=\@,CEHKa$9$ V|8d V8!H$~'**,/2p5@8;=@CPF|^`|a$ WXYZ[\[>$ P~>z& f X# &@)+.J1427:!N$'0*,/2v5F8;=@CVFa$6$ Pj \>!N$'0*,/2v5F8;=@CVF$dNa$,-./01234>$ P|d V8!H$~'**,/2p5@8;=@CPFD$dN^`Da$.$ P|d V8!H$~'**,/2p5@8;=@CPFa$4wxyz{    [>$ P|d V8!H$~'**,/2p5@8;=@CPFD$dN^`Da$.$ P|d V8!H$~'**,/2p5@8;=@CPFa$6$ P|d V8!H$~'**,/2p5@8;=@CPF$dNa$ y z { | } E!!!"""""" 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