Modification request form

This field is for validation purposes and should be left unchanged.

IACUC Protocol Number:(Required)

Protocol approval date(Required)

Protocol title(Required)

Principal Investigator's name(Required)

Email

1. Nature of modification

Please describe all changes to the original protocol, using lay terms. Describe any changes in procedure, chemotherapeutics, or species. To make personnel changes, see section II. To request additional animals, see section III. Section IV must be completed for all changes which have the potential to increase animal pain or distress or includes new or additional procedures, a change in anesthetic agent, an increase in animal numbers greater than 10%, the addition of animal species or a change in Principal Investigator. Signatures in Section V required in all cases.

Type of modification(Required)

2. List training/enrollment dates for all personnel including the PI

● The Collaborative Institutional Training Initiative quiz (CITI working with the IACUC: investigators, staff, and students; basic course). Access through Citiprogram.org

● The Collaborative Institutional Training Initiative quiz for Responsible Conduct of Research (RCR)

● Enrollment in the NAU IACUC Occupational Health Program (OHP)

● Completion of any other IACUC mandated training that is relevant to the protocol request

Name

CITI Investigators, staff, students basic course quiz date

RCR quiz date

OHP date

Other mandated training

Provide a brief description of training and experience (include past training) with the species and procedures/techniques proposed in this protocol.

Name

CITI Investigators, staff, students basic course quiz date

RCR quiz date

OHP date

Other mandated training

Provide a brief description of training and experience (include past training) with the species and procedures/techniques proposed in this protocol.

Name

CITI Investigators, staff, students basic course quiz date

RCR quiz date

OHP date

Other mandated training

Provide a brief description of training and experience (include past training) with the species and procedures/techniques proposed in this protocol.

Name

CITI Investigators, staff, students basic course quiz date

RCR quiz date

OHP date

Other mandated training

Provide a brief description of training and experience (include past training) with the species and procedures/techniques proposed in this protocol.

3. Addition of Species / Increase in Animal Numbers

Please state the additional number of each species required for the completion of the protocol. Provide justification for changes in the space below.

Species/Common name

Strain/Breed

Gender

Year 1

Year 2

Year 3

Or year 3 Total

Species/Common name

Strain/Breed

Gender

Year 1

Year 2

Year 3

Or year 3 Total

Species/Common name

Strain/Breed

Gender

Year 1

Year 2

Year 3

Or year 3 Total

Species/Common name

Strain/Breed

Gender

Year 1

Year 2

Year 3

Or year 3 Total

Species/Common name

Strain/Breed

Gender

Year 1

Year 2

Year 3

Or year 3 Total

Total strain/breed

Total gender

Year 1 Total

Year 2 Total

Year 3 Total

Or 3 Year Total

Describe justification for new species or increase in animals:

4. USDA Pain Categories

Based on the level of pain/distress to animals. Procedures that are painful/cause stress in humans should be considered to do the same in animals. Consult the attending veterinarian for assistance in determining the appropriate category.

Pain categories of animals in protocol

Pain Category B

List approximate totals of Category B animals

Pain categories of animals in protocol

Pain Category C

List approximate totals of Category C animals

Pain categories of animals in protocol

Pain Category D

List approximate totals of Category D animals

Pain categories of animals in protocol

Pain Category E

List approximate totals of Category E animals

5. Assurance of Review of Existing Literature

If your modification has the potential to increase pain or distress to animals or includes new or additional procedures, a change in anesthetic agent, an increase in animal numbers greater than 10%, the addition of animal species or a change in Principal Investigator you must complete this section. Provide a written explanation in sufficient detail to assure the IACUC you have reviewed the scientific literature to determine that (1) this study does not unnecessarily duplicate prior work at this or any other institution, (2) there are no reasonable alternatives to the use of animals (such as less sentient animals, computer models or tissue culture), and that (3) there are no alternatives to any painful procedures proposed here.

Specific points to be addressed include:

Names of the databases searched(Required)

Date the search was performed(Required)

Period covered by the search (i.e. Medline years 1966-present, etc.)(Required)

Key words and/or the search strategy used(Required)

Results of the search(Required)

Written explanation(Required)

Personal knowledge alone are not sufficient to enable IACUC assurance of this review and hence approval of your request but in some circumstances as in highly specialized fields of study, conferences, colloquia, subject expert consultants, or other sources may provide relevant and up-to-date information regarding alternatives in lieu of, or in addition to, a database search.

VI. Approvals and Certification

By checking this box, I agree that to the best of my knowledge, the information herein is accurate and complete. I have carefully compared the proposed work with the current literature and it is my professional opinion that the proposed work meets high standards of scientific merit and does not unnecessarily duplicate previous studies. All personnel listed understand their responsibility in complying with University policies governing the care and use of animals. All animal related activities will be performed by qualified individuals. Technicians and students involved have or will be trained in proper animal handling, administration of anesthetics, analgesics, euthanasia, and other laboratory / field procedures to be used in this protocol. I understand that should the conduct of the protocol require a material change from that stated herein, approval by the IACUC is required before I may proceed to implement the change.(Required)

Yes, I agree to this statement

Principal Investigator

First Last

Date

ON THIS PAGE

Modification request form

IACUC Modification Request form

1. Nature of modification

2. List training/enrollment dates for all personnel including the PI

3. Addition of Species / Increase in Animal Numbers

4. USDA Pain Categories

5. Assurance of Review of Existing Literature

VI. Approvals and Certification