Tissue transfer form

Northern Arizona University
Institutional Animal Care and Use Committee

Application for Animal Tissue Transfer

Instructions: This form is to be used for the transfer of animal tissues from another institution/agency that will be used in the conduct of research at NAU. Submit the completed form to the IACUC Coordinator at Box 5640 in the Department of Biological Sciences (Building #21) or deliver directly to the Biological Sciences Annex (Building 21B).

Scope: In addition to the oversight of the humane care and use of laboratory animals, the IACUC, the Office of Regulatory Compliance (ORC) and the institution’s Biosafety Officer (BSO) oversee the transfer, delivery, use and disposal of animal tissues at NAU

Policy: This policy strictly covers vertebrate animal tissues. In order to document practices of acquisition, delivery and use, tissues are typically required to be collected under an IACUC approved protocol. Tissue transfer submissions are reviewed by the Attending Veterinarian (AV) or IACUC representative and the BSO.

Description: The following descriptions can assist in determining if a tissue transfer form is required.

– Tissue Collected under an approved NAU IACUC protocol: Does not require a tissue transfer form, however shipping and receiving training and any additional training or review from the ORC may be required prior to transfer.

– Tissue collected under another institution’s approved protocol: A tissue transfer form is required to bring these tissues to NAU for research purposes. In addition, shipping and receiving training and any other necessary training or review from ORC may be required prior to receipt of tissues.

– Tissue collected legally but not under an approved protocol: Such as tissues collected by a state, federal or private organization and donated for research at NAU. A tissue transfer form is required. The recipient will need to show proof that the tissues were collected legally. This proof can come in the form of a written document, copies of collection permits, etc.

– Tissue submitted for clinical analysis on campus that are not used for teaching or research: No tissue transfer form is required. However shipping and receiving training and any other necessary training or review from ORC must still be completed before receipt of tissues.

– Fixed tissue specimens being shared between institutions: Does not require a tissue transfer form, however shipping and receiving training and any additional training or review from the ORC may be required prior to transfer/ receipt.

Provide the following information

NAU Principal Investigator(Required)

First Last

Department(Required)

Campus phone number(Required)

Campus email(Required)

Protocol title/number(Required)

Tissue source

Name(Required)

First Last

Phone number(Required)

Email(Required)

Institution(Required)

Protocol number/title under which tissue was collected(Required)

OLAW Welfare Assurance Number(Required)

Tissue requested

Species(Required)

Tissue type(Required)

Quantity(Required)

Frequency of transfer(Required)

Method of transfer(Required)

Hazard potential

Has the tissue been screened for human/animal pathogens?(Required)

Yes

Will tissue be treated (preserved, digested, etc.) prior to transfer to NAU?(Required)

Yes

If yes, provide a description of how tissue is treated:

Will tissue be transferred into live animals?(Required)

Yes

If yes, provide protocol information describing procedure:

Was the animal intentionally or otherwise suspected to be infected?(Required)

Yes

If yes, provide information on the organism/disease:

Are there any additional hazards associated with this tissue?(Required)

Yes

If yes, provide description of hazard:

Tissue Use

Briefly describe how tissue will be used:(Required)

Describe method of tissue disposal:(Required)

Personnel Training

Describe personnel training for procedures with this tissue:(Required)

Permits: It is the responsibility of the PI/Research Leader to have all necessary permits from regulatory agencies such as CDC, FDA, Fish and Wildlife, etc., in place prior to receipt of tissue. Applicants are encouraged to contact the ORC for guidance.

Shipping and receiving: Tissue transfer must be conducted in accordance with federal shipping and importation guidelines. The PI is responsible for being in compliance with all regulations regarding shipping tissues that may have been exposed to animal diseases or present a zoonotic risk to humans. The NAU BSO can provide Standard Operating Procedures (SOPs) for sample handling and transport and detailed information on USDA, CDC, APHIS, and PHS regulations. Hazardous sample shipping and receiving courses are available and must be completed before tissue transfer to NAU.

Location/safety measures

Indicate the building and room number where the tissue will be kept.

Describe safety and containment measures taken to prevent spread of potentially infectious disease contained in the tissues. Describe security measures taken to prevent theft/loss of tissue. Facility may be inspected prior to tissue delivery.

Signatures: PI must initial the following, verifying that each statement is true:

This description is accurate and complete. All personnel are adequately trained to perform these procedures and are enrolled in the occupational health program. Safety practices will be adhered to. All vertebrate animal tissues will be acquired through lawful means, judiciously used and disposed of appropriately. I have read and understand the guidelines associated with this application.(Required)

Initial

Tissue proposed for use is not from an endangered species.(Required)

Initial

Tissue shipment does not violate the Convention of International Trade of Endangered Species (CITES).(Required)

Initial

Tissue proposed for use and its shipment does not violate the Migratory Bird Act.(Required)

Initial

By checking the box, I certify that to the best of my knowledge, the information included herein is accurate and complete.(Required)

Yes, I agree with this statement.

Date(Required)

MM slash DD slash YYYY

ON THIS PAGE

Application for Animal Tissue Transfer

Provide the following information

Tissue source

Tissue requested

Hazard potential

Tissue Use

Personnel Training

Location/safety measures