INSTITUTIONAL ANIMAL CARE AND USE COMMITTEE (IACUC)

987830 Nebraska Medical Center

Omaha, NE 68198-7830

402/559-6046

Fax 402/559-3300

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REQUEST FOR CHANGE

Section I-Cover Page

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Instructions: A change includes any difference in the approved protocol, i.e., title, personnel responsibilities, qualifications, and/or experience; project overview, justification of the number of animals requested; project design, preparative regimen; pain control during procedures; procedures; post-procedure monitoring; post-procedure analgesic agents; potential pain, discomfort, and/or distress; euthanasia endpoints, exceptions to regulations/polices, disposition of animals, biohazardous material, method of euthanasia, and site of study.

IACUC #:

TITLE OF PROTOCOL:

PRINCIPAL INVESTIGATOR:

DEPT:

CAMPUS ZIP:

PHONE:

EMAIL ADDRESS:

Indicate below the type of change(s) you are requesting and complete the appropriate documents as indicated:

1. Change in Study Title-The title of your approved IACUC application can be changed (additions or deletions made) for any reason, but changes in title are not required by either Sponsored Programs or the IACUC. The change(s) in title may not be adequate to ensure the funding agency that the Institution has approved the use of animals in your grant. If you have any further questions, contact Sponsored Programs Administration.

List Titles to be Added:

List Titles to be Deleted:

2.Change in Protocol. Complete Section II-Change in Protocol.

3.Change in Study Personnel. If NO change in Study Personnel, please delete Section III prior to submission.

Personnel Deletion. PI should ensure that responsibilities of these personnel are covered by remaining or

added personnel. List Personnel to be deleted:

Personnel Addition. Complete Section III-Study Personnel Change/Update

Update to Currently Approved Personnel- Responsibilities and/or Qualifications. Complete Section III-

Study Personnel Change/Update

Change in Contact(One Only)Name: Email Address:

Investigator Certification

Signaturebelow or electronic submission of this form certifies that the proposed changes are necessary for either scientific, animal welfare or grant application reasons in order to continue the project.

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______

Signature of Principal Investigator Date

IACUC RFC Form (Revised 12/08)

Section II-Change in Protocol

Per requirements of the PHS Policy on Humane Care and Use of Laboratory Animals, USDA Animal Welfare Act and Regulations, Guide for the Care and Use of Laboratory Animals,Association for Assessment and Accreditation of Laboratory Animal Care International, the UNMC/UNO Animal Welfare Assurance,and the Animal Care and Use Program Policies and SOPs located on the IACUC website, changes in approved research protocols cannot be initiated without IACUC review and approval.

Submission of a revised IACUC applicationthat incorporates the changes described below in all appropriate Sections is required. Changes to text must be in brackets and dated for clarity. For example, [7/15/13, this is a new procedure]. This method ensures one complete, up-to-date document. Submissions without a revised IACUC application in the format described above will be returned without review.

1.Requested Change(s): Check all that pertain and be sure to address the applicable sections on the submitted revised IACUC application.

Project Overview

Project Design

Project Endpoint

Number of Animals

Indicate what species and how many total additional animals you are requesting:

Field Studies

Preparative Regimen

Procedures

Anesthetics, Sedatives and/or Analgesics During Procedure

Post-Procedure Pain Analgesics

Post-Procedure Management

Breeding Animals

Potential for Pain, Discomfort and/or Distress

Frequency/Duration of Monitoring

Premature Euthanasia/Humane Endpoints

Exceptions to Regulations/Guidelines/Policies

Disposition of Animals

Method of Euthanasia

Method to Ensure Death

Hazardous Material

Site of Study

Other

2.Description of Change(s). Provide a summary description of each proposed change in protocol and state the rationale for each change.

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3.Impact on Animal Well Being. Are you adding a new or revised procedure and/or condition that will potentially cause more than momentary pain, discomfort, or distress?

No Therequest for change does not include induced or spontaneous conditions, phenotypic

attributes, and/or procedures that will cause more than momentary slight pain, discomfort, or

distress.

YesThenew or revised procedure(s) and/or condition(s) will potentially cause more than

momentary pain, discomfort, or distress. UpdatePotential Pain, Discomfort, and/or Distress Section.

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Section III- Study Personnel Change/Update

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  • Complete parts 1-4 for each individual.The IACUC must ensure that personnel conducting procedures on animals are appropriately qualified and trained in those procedures OR that an appropriate training plan is proposed.
  • Refer to “Requirements for Animal/Animal Facility Access” for instructions.

1. Personnel Information

Name:
Role:
X one of the following. / PI: / Secondary Investigator:
Technician/Technologist: / Student:
Postdoctoral Associate: / Research Associate:
Faculty Advisor:
Phone:
Email:

2. Education

Institution and Location / Degree / Year / Field of Study

3. Current Career Skills and Protocol Specific Responsibilities

  • Current Skills - Check all current career skills under the species they been performed on.
  • Protocol Responsibilities- Check the procedures you will be responsible for on this protocol under the species they will be performed on. NOTE: Responsibilities that you will need to be trained in must be addressed in Part 4.
  • For other species please type the names in the extra column(s).

Current Skills / Protocol Responsibilities
PROCEDURES / Mice / Rats / Hamsters / Rabbits / Swine / NHP / Mice / Rats / Hamsters / Rabbits / Swine / NHP
Routine Care
Handling & Restraint
Injections:
IV
IM
SC
IP
IC
Blood Collection:
Tail vein
Jugular vein
Leg veins
Maxillary vein
Saphenous vein
Ant. vena cava
Orbital sinus
Cardiac puncture
Cut downs
Surgeries (List):
Procedures (List):
Anesthesia:
Inhalant
Injectable
Aseptic technique
Intra-operative Monitoring
Post Procedural Monitoring
Breeding Colony Management
Identification:
Ear punch
Ear tag
Tattoo
Toe clipping
Genotyping
Euthanasia:
CO2
Inhalation
Injectable
Decapitation
Cervical dislocation
Other:

4. Training to be Provided

  • For the protocol responsibilities that you need to be trained in, please complete the following: Note: Experienced personnel that will provide training must be listed on this protocol.

Species / Procedure / Training Technique (i.e., reading, observation, performed with supervision) / Person Providing Training

5. PI Assurance. Submission of this form indicates assurance by the PI that the following will be adhered to:

  1. All listed study personnel that are to be trained will be supervised by qualified individual(s) until such time that the individual is qualified to work independently.
  2. Training records on this individual will be kept on file and are subject to periodic and unannounced inspections by the IACUC, CM or UNO animal care staff, the Protocol Assessment Liaison (PAL), and other regulatory and accreditation agencies as necessary.

*To continue with additional personnel please copy and paste the entire form at the beginning of a new page.

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