Home > Office of Grants and Contracts > Resources > Forms > Animal Use Proposal

Office of Grants and Contracts


ANIMAL USE PROPOSAL
(in accordance with the Valdosta State University Policy on Humane Care and Use of Laboratory Animals)

Final Use Category Assigned (circle): A B C D AUP No. __________________________
IACUC Approval Signature: ___________________________________________________
Date of Approval: ___________________________________________________________
IACUC Reviewer: ___________________________________________________________

This form has been developed to facilitate the review of requests to use animals for specific research, teaching, or biological testing projects. The review process has been designed to communicate methods and materials for using animals through administrative officials and attending veterinarians to the Institutional Animal Care and Use Committee (IACUC). This process will help assure that provisions are made for compliance with the Animal Welfare Act, the Public Health Service Policy on Humane Care and Use of Laboratory Animals (10/00), and the Department of Health and Human Services’ 1996 Guide for the Care and Use of Laboratory Animals, http://grants.nih.gov.grants/olaw/olaw.htm. This completed form must be approved by the IACUC before the project or course is initiated and before animals can be procured. Approved AUPs and AUP numbers are valid for up to three years subject to approval of modifications and annual reviews.
Use this form only for NEW AUPs or for those whose 3-year approval for use has expired.

For ANNUAL REVIEWS or MODIFICATIONS to an approved AUP, use the 1-page “AUP Annual Review or Modification” form. After 3 years a new complete AUP must be submitted and assigned a new AUP number. The number of animals used must be declared annually and their documentation is the responsibility of the Principal Investigator.

MULTIPLE FUNDING AGENCIES: Submit only one AUP for identical procedures, animal species and numbers of animals proposed in grant requests to different funding agencies. Use the same AUP number for each grant application. If funded, submit “AUP Annual Review or Modification” form with changes from original AUP, such as funding agency, procedures, or number of animals. Unless authorized by a Modification, the number of animals used must not exceed the number authorized on the original approved AUP regardless of the sources of funding.

1. Project or Course Title:
2. Name of Principal Investigator: E-mail:
Title of PI: SSN
Department (Bldg./Room):  
Please list all persons from your laboratory who will work with animals and the procedures they will perform:
Name: Procedures:
Name: Procedures:
Name: Procedures:
Source of Funding: Proposal Deadline:
Anticipated Starting Date: Study Completion Date:
4. The PI assumes responsibility for compliance with the policies stated above including assuring that the staff are trained and qualified to perform the procedures on animals as indicated in this Animal Use Proposal and assures the Committee that this research does not unnecessarily duplicate previous experiments. The PI must hold VSU faculty status. Students, including post-docs, residents and others “in training,” and non-VSU employees can only serve as Co-Investigators.
The Attending Veterinarian verifies that the elements of this proposal have been assessed regarding the use of appropriate techniques in utilization of animals and that consultation with the PI will occur as necessary to resolve issues to minimize pain and distress.
 
Signature of PI: ______________________________________ Date:
Attending Veterinarian: Date:
 
Please submit this completed form through your Grants and Contracts Office: Compliance Coordinator, Room 115, Regional Center for Continuing Education (RCCE), Valdosta State University, Valdosta, GA 31698
Phone: (229) 259-5045 FAX: (229) 245-3853
 
5. For all proposals submitted, particularly those related to U.S. PHS or NIH proposals, please complete this item: The Dean, Department Head, or College Review Committee (indicate by underline) concurs with the scientific relevance of conducting this protocol.
Printed Name: Signature: __________________________________________________________
6. Will any aspect of the experimental study (course) or animal husbandry be conducted at another institution? Yes No
If Yes, where?
Was the proposal approved by the IACUC of that institution? Yes No
7. Abstract of Proposal: Describe succinctly, in lay terms, how the animals will be used and what the contribution from using animals will be. Continue on separate page, if necessary, or attach your project abstract.
8. Does this proposal include the maintenance of a breeding colony? Yes No
 
9. Animals to be used in this study per year:
Animal Species
(Common name)
Max. No.
Strain
Sex
Facility
Location **
Source
*For breeding colonies, indicate the maximum number to be maintained in the colony at any time.
Note: Excluding breeding colonies, the number of animals procured and the number of animals used under this AUP must be documented by the investigator each year. By law, this number must not be greater than the maximum approved in this AUP.

**For additional space use bottom of this page or add a page.
 
10. a) Explain why the species was selected.
b) Explain how the numbers needed were determined.
11. Indicate non-surgical procedures below and describe on a separate sheet.
a) Specimen collection from live animals:
 
Type and volume of samples:
 
Frequency and duration of collection:
 
Method of collection:
b) Specimen collection from euthanized animals:
 
Type:
 
Source:
c) Induction of neoplasia:
 
Type:
d) Use of infectious agents (Request approval from Environmental Health Officer)
 
Name of agent:
 
Amount of dose:
 
Route of administration:
 
Biosafety level:
e) Use of radioisotopes (Request approval from Environmental Health Officer):
 
Isotope:
 
Amount/Dose:
 
Route:
f) Use of carcinogens (Request approval from Environmental Health Office):
 
Carcinogen:
 
Amount/Dose:
g) Administration of test substances not listed above:
 
Amount/Dose:
 
Route:
h) Tranquilizers, anesthetics, analgesics or antagonists used in any of the above procedures (specify below):
Species
Agent/Conc.
Dose (mg./kg.)
Route
NOTE: The Institution does not condone any project involving pain without anesthetic/analgesia.
 
12. Indicate Surgical Procedures:
a) Type of surgical procedure. A complete description on a separate page should include who will administer and what the pre- and post-operative care will consist of, special post-surgical needs of the animal, the length of time the animal will be kept alive following surgery, and any anticipated complications.

Terminal, i.e. animals will be euthanized under anesthesia when surgery is completed.
Yes No
 
NOTE: Describe fully any euthanasia method to be used and the reasons for the selection (list by name of drug, dosage and route of administration). See question 13.
b) Anesthetic and analgesic agents to be used in surgical procedures:
Species
Agent/Conc.
Dose (mg./kg.)
Route
 
c) Indicate monitoring and life support systems to be utilized.
Respiratory Rate
Heart rate
Mucous Membrane
Color Reflexes
EKG
Blood Gases
Body Temperature
Blood Pressure
Other
    
 
13. Euthanasia procedures:
a) Technique Species:
 
CO2:
 Inhalation:
Security Image

(form security image)


*Please enter the security code shown above:

If you unable to read the image please click this link: change image