Institutional Animal Care & Use Committee (QU-IACUC)

(All Forms Must be Typed)

Please note:

  • Following the review of the amendment, theQU-IACUC may request the full animal use application form be submitted.
  • Often filled applications forms are sent back to researchers for additional information. If care is taken to provide sufficient detail in the original application, then delays in their approval can be avoided.
  • All renewals are issued for a period of one year only. Further renewals should be sought at each expiry based on the project’s timeline

QU-IACUC Approval Number: / Issued On
Expiry date of previous QU-IACUC ethics approval:
Title of Research Project:
Project ID:
Source of funding:
Principal Investigator(s):
College/Department/Center:

Nature ofSubmission: please check all that apply and explain changes (double click on the box)

Renewal Amendment (please choose nature of amendment below)
Change in Animal Numbers, requested number: ______
(Justify therequested number of animalsbelow) / Change in Protocol
Change in Personnel
List name(s) in space provided below. Indicate which projects they will be working on and specify their “role on project”, i.e., surgery.
NOTE: All new personnel must enroll into the designated CITI program and submit all certificates needed. / Change in Animal Housing
Use of biohazardous Agents. Check this box if any change involves the use of a hazardous agent and submita copy of this form to the University Biosafety Committee and/or Radiation Protection Services for approval. / Other, Specify:
  • In the space below, provide details AND reasons for proposed changes/additions to the originally approved proposal. Proposed changes must be clearly identified and contrasted with previously approved protocol.
  • Is the project being carried out as described in the original submission to QU-IACUC? Yes No

If no, please explain the discrepancies in the space below.

  • Has any of the animals utilized suffered any serious or unexpected harms, toxicities or side effects?

Yes No If yes, please describe.

  • Have there been any internal or external audits of the research, preliminary (stopping rule) analyses, reports of data and safety monitoring boards.. etc? Yes No

If yes, please describe

  • Has there been any significant change in the information on which the QU-IACUC provided ethics approval for, e.g., new knowledge from the literature, from the present project or from other related sources?

YesNo

If yes, please describe the new information, and indicate how it differs from that in the previous or original ethics approval, and its impact on the ethics of the research underway.

  • Have any amendments been made to the application since its original approval? YesNoIf yes, please explain them.
  • Were these amendments approved by the QU-IACUC? Yes No

If yes, when? If no, why not?

  • Are you now requesting any further amendment(s) to the original application? Yes No

If yes, please describe and justify the proposed amendment(s).

  • When do you expect the project to be completed? (please provide month and year)

Important:

If the project and/or the previously approved research protocol have changed since the original submission was approved, or are requested at this time, please provide the current or proposed versions of research proposal and indicate where the changes were made.

______
Principal Investigator

Address & Contacts

______
Date

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Please do not write below this line. This part is for QU-IACUC use only:

Renewal/Amendment Request received on: Date______

Renewal/Amendment Issued for Period: ______to ______(One Year)

Next Renewal Due by: ______

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