ANA G. MENDEZ UNIVERSITY SYSTEM

Vice Presidency for Planning and Academic Affairs

Associate Vice Presidency for Sponsored Programs and Compliance

Office of Regulatory Compliance

ANIMAL CARE AND USE COMMITTEE(ACUC)

ANIMAL STUDY RENEWAL FORM

(Incomplete applications will not be evaluated by ACUC)

(Application must be completed in computer using font Times New Roman size 10-12)

For official use only

ACUC No. / Date Approved
(Month/Day/Year)
/ / / Expiration Date
(Month/Day/Year)
/ / /

Instructions: Complete this form in all its parts. If an item does not apply, indicate it by typing N/A. After signatures of the Principal Investigator, Attending Veterinarian and Facility Manager are obtained. The Animal Study Renewal Form is sent electronically by the Principal Investigator to the Institution’s Office of Regulatory Compliance. Although an electronic submission is required, it does not eliminate the need to provide the Institution’s Office of Regulatory Compliance with three (3) hard copies, one of them containing original signatures (blue ink signatures).

I. Basic information

  1. Protocol Title:

  1. ACUC Number:

  1. Principal Investigator
/ Last Name First Name / Academic Degree
  1. Telephone /Extension /Fax
/ Telephone Extension Fax
  1. Mailing Address

  1. Institution and Department

  1. Student:
/ YesNo (If selected, please specify):
  1. Mentor/Co-PI
/ Last Name First Name / Academic Degree
  1. Telephone /Extension /Fax
/ Telephone Extension Fax
  1. Funds

  1. Initial Approval Date(Month/Day/Year)
/ / /

II. PROTOCOL RENEWAL INFORMATION

1. Modifications Yes No
If Yes, include the Animal Study Amendment Form for major or minor modification.
Please provide a summary of any protocol changes, including any new objectives, if applicable.
2. Justify your request forextending the study.
3. Year of the Renewal Request (4thand 7thyear renewals have to submit the Animal Study Proposal Form).
2nd year renewal / 5th year renewal / 8th year renewal
3rd year renewal / 6th year renewal / 9th year renewal
4. Project Status / 5. Common and Scientific Name of AnimalSpecies(Strain if applicable).
Active Inactive (project never initiated)
6. Number of Animals Used (per year)
Provide the number of animals used and/or to be used in the following years. / Year 1
(or Year 4) / Year 2
(or Year 5) / Year 3
(or Year 6)
Number of animals
Gender
Weight and age
TOTAL NUMBER OF ANIMALS FOR A THREE YEAR STUDY

III. COMPLICATIONS ANDUNANTICIPATEDPROBLEMS

1. Was there any unusually high frequency of serious but anticipated adverse events? Yes No
a. If yes, describe the findings.
2. Did animals suffer from any adverse event? Yes No
a.If yes, describe the event and explain the impact on the project.
3. Do these unanticipated events, affect the number of animals used or needed in order to fulfill the purpose of the study?
Yes* No *If yes, please complete the following table, followed by a brief description of the event.
Animals Characteristics / # Animals assigned
(Year 1) / # Animals used
(Year 1) / # Animals assigned
(Year 2) / # Animals used
(Year 2) / # Animals assigned
(Year 3) / # Animals used
(Year 3)
Gender
Weight (age)
Total
TOTAL NUMBER OF ANIMALS FOR THE THREE YEARS OF THE STUDY
*Provide a brief description of the anticipated event (s):

IV. STUDY RESULTS

1. What results (preliminary or final) have been obtained in the study?
2. Have any research results that are relevant to the modification or continuation of this study been published or presented? Yes No If yes, explains these findings.
3. Select the Literature Searches that apply to your study.
Unnecessary procedures are not being duplicated from previous experiments. (Provide two current literature searches to demonstrate that the study is not duplicative. Include results of current literature search, description of search engines and keywords used).
USDA Category D or E (Enclose two current literature searches thatdemonstrate alternative methods and procedures to minimize pain and discomfort. Describe search engines, results and keywords used).
I certify that all information provided is true and correct:
Print name of Principal Investigator/Student / Signature (blue ink only) / / /
(Month/Day/Year)
Print name of Mentor/Co-Investigator
(If applicable) / Signature (blue ink only) / / /
(Month/Day/Year)
Print name of Dean / Signature (blue ink only) / / /
(Month/Day/Year)
Print name of ACUC Veterinarian (If applicable) / Signature (blue ink only) / / /
(Month/Day/Year)

Please submit all materials to the Office of Regulatory Compliance at your institution:

UMET (787) 766-1717 ext. 6362/fax (787) 751-3379E-mail:

UNE (78) 257-7373 ext. 2279E-mail:

UT 787-743-7979 ext. 4126 E-mail:

Or, Fax (787) 759-6411,E-mail:

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Revised (6/2012)Eng_vers_1