Please use this form to request assignment of animals to two IACUC protocols within a limited scope of procedures. The primary protocol will be the protocol, to which the animals are assigned, and the secondary protocol will be the protocol, to which the animals are dually assigned for a designated period of time (see Dual Protocol Allocation policy*). Please contact the Office of the IACUC (OOTI) () for further information.

Primary IACUC Protocol #: / Primary Principal Investigator (PI): / Primary PI Email:
Secondary IACUC Protocol #: / Secondary PI: / Secondary PI Email:
Dual Assignment Information.
1.  Describe the intersection of the two protocols including a chronological summary of all procedures during the dual assignment period†:
2.  Indicate the time period of use for the dual assignment:
Estimated start date: / Estimated end date:
3.  Indicate the number of animals, to which the dual assignment will apply:
☐ All animals in the primary protocol / ☐ Specific number of animals (provide # here):
ASSURANCES. By signing below, you attest to the following statements:
·  I certify that I have reviewed the secondary protocol and agree that the activities do not interfere with the scientific validity of the experimental results, the sampling schedule or sampling limits, or other aspect of the primary protocol. I have read and will comply with the IACUC policy on dual assignment of animals, and will amend my protocol if necessary. I will be responsible for signing the sample request form for the secondary protocol.
Primary PI Signature/Date:
·  I certify that I have reviewed the primary protocol and agree that the activities of the secondary protocol do not interfere with the scientific validity of the experimental results, the sample schedule or sampling limits, or other aspects of both protocols. I have read and will comply with the IACUC policy on dual assignment of animals.
Secondary PI Signature/Date:

·  *Note: eCommons login is required to access HMA IACUC policies.

·  †Note: Please include flowcharts outlining the procedures described in Question 1. Each primary and secondary flowchart must include reference to the other protocol. If the animal will undergo any major surgeries on the second protocol, then the dual assignment request will NOT be approved.

·  When complete, submit form to the OOTI for processing. Approval of protocols that use animals assigned to other protocols binds the PI to an agreement that coordinates all animal sampling and procedures with the corresponding PI, so that all procedures follow the guidelines by the relevant governing agencies and the IACUC.

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