UNIVERSIDAD CENTRAL DEL CARIBE
INSTITUTIONAL ANIMAL CARE AND USE COMMITTEE
MODIFICATION REQUEST FORM
· This form is required to request changes to an approved IACUC protocol.· Any changes requested cannot be implemented prior to IACUC review and approval.
· This form must be submitted via email to or . Other modification requests will be sent to the Committee for review. The IACUC can request at any time that a new protocol be submitted if they determine that too many modifications have been made to the original protocol application making it unclear.
· The following items cannot be requested using this form. A new protocol application must be submitted to incorporate the following changes:
§ Changing the species used
§ Adding procedures that do not logically relate to the specific aims of the original protocol
§ A proposed major change in the scientific aims of the original protocol application
§ Switching from non-survival to survival surgery
§ Switching from single to multiple major survival surgeries (major surgery opens a body cavity)
When submitting a new protocol application for any of the changes above, please reference your current IACUC protocol number and explain the changes that you have added. This will assist the IACUC administrative staff in increasing the efficiency of your protocol review.
§ Requesting more than a 25% increase in animals can be submitted for review; however the IACUC generally requires that in most cases requests above 25% will require a new protocol application.
§ If you have any questions regarding this form, please contact with Prof. Zilka Rios, President of IACUC office at (787) 799-3001 extension 2082.
Form: UCC/MRF2013-12-12
UNIVERSIDAD CENTRAL DEL CARIBE
MODIFICATION REQUEST FORM
INSTITUTIONAL ANIMAL CARE AND USE COMMITTEE
A. Protocol Information1 / Principal Investigator
2 / Approved Protocol Number
3 / Protocol Title
4 / Phone Number
5 / Email Address
B. Modification Information (only complete sections which apply to the changes you are requesting)
6 / Addition or deletion of an investigator
Name / Position
title / E-mail / Phone # / Add or delete
Indicate if the person is listed on an animal protocol from a Universidad Central del Caribe or Institution other than the Universidad Central del Caribe.
If any of the personnel being added to this protocol are listed on animal protocols outside the Universidad Central del Caribe, please indicate the University or Institute for each person. The purpose of this question is to identify individuals who travel between different animal facilities and therefore may provide for potential cross- trafficking of infectious organisms.
C. PROTOCOL TITLE CHANGE OR ADDITIONAL PROTOCOL TITLE
7 / Previous title
8 / New title to replace previous title
9 / Additional title requested
10 / Previous title
11 / Please state why these changes are requested
D. CHANGE IN FUNDING SOURCE
12 / Previous funding source(s)
13 / New funding source(s)
(If an outside grant(s), include title and number)
14 / Please state why these changes are requested
Please note that if the New Funding Source represents NIH Funds, you must also submit a just-in-time-review so that the IACUC can ensure the animal research described in the New Funding Source is contained in the IACUC protocol.
E. ANESTHETIC/ANALGESIC CHANGES
Proposed Anesthetic / Dose (mg/kg) / Route
15 / Please explain why you are adding/changing the anesthetic/analgesic.
16 / Please indicate how you will monitor effectiveness of anesthetic/analgesic.
F. CHANGE IN EUTHANASIA PLAN
17 / Previous Method of Euthanasia
18 / Proposed Method of Euthanasia / Dose / Route
19 / Previous Method of Euthanasia
Is this method accepted by the 2000 AVMA Panel on Euthanasia?
(for more information, please visit: www.avma.org/resources/euthanasia.pdf )
20 / Please explain why this change is necessary.
G. CHANGES IN SURGICAL PROCEDURE(S) OR ADDITIONAL SURGICAL PROCEDURE(S) REQUESTED
21 / Please describe the change in surgical procedure or additional surgical procedure
22 / Why is this change needed?
23 / Will this change require additional animals? (If Yes, you must fill out section H). / Yes ( ) No ( )
24 / Will anesthetics/analgesics be given?
If yes, section E must be completed / Yes ( ) No ( )
25 / Please describe any expected and/or potential complications. You answer must include the frequency of these complications and how you will address them.
H. REQUESTING AN INCREASE IN ANIMAL NUMBERS
(Please specify number of animals by: week, month or per year).
Species / Strain / Number of Additional Animals Requested / % Increase from original protocol
26 / Please explain the need for additional animals and offer statistical justification when appropriate. The IACUC generally requires that increases above 25% require a new protocol application; however all requests will be reviewed.
I. A NON-SURGICAL PROCEDURE
27 / Please describe the change or additional procedure.
Please provide justification (s).
J. CHANGES IN ANIMAL STRAIN
28 / Species Used:
29 / Previous Strain Used:
30 / Proposed Strain:
31 / Will this change require additional animals? (If Yes, you must fill out section H)
32 / Please state why this change is necessary.
K. SPECIAL HOUSING REQUESTS
33 / Please explain in detail your request for special housing considerations.
34 / Why are these changes necessary?
L. CHANGE IN HUSBANDRY PROCEDURES
35 / Please explain in detail the changes you are requesting regarding the animal husbandry:
36 / Why are these changes necessary?
M. MODIFY OR ADD NEW TESTS OR AGENTS
Please list which agent(s) you wish to add to your protocol: / Dose / Route / Frequency / Duration of treatment
37 / Biological: (tissues or fluids, rDNA, tumor cells, non-replicating viruses)
38 / Radioisotopes or ionizing radiation
39 / Hazardous Chemicals
40 / Antibiotics
41 / Why are these changes requested?
42 / Will this change require additional animals? (If Yes, you must fill out section H).
43 / Describe any expected or potential complications that may arise as a result of these new tests or agents. You must also describe the frequency for each complication and indicated how you will address each complication should it arise.
N. OTHER CHANGES THAT LOGICALLY RELATE TO THE SPECIFIC AIMS OF THE ORIGINAL PROTOCOL APPLICATION
44 / Please list any other changes that need to be made to the IACUC application that are not addressed above and please explain why these changes are needed.
O. APPLICANT’S CERTIFICATION
The information provided in this form accurately represents the changes I propose for my previously approved IACUC application. I am aware that the Applicant’s Certifications, which I agreed to on the original application, will remain in effect.
Signature
Date
FOR OFFICIAL USE ONLY
COMMITTEE MEMBER
NAME / COMMITTEE MEMBER
SIGNATURE / COMMENTS
1. Dr. Pedro Ferchmin
2. Dr. Krishna Baksi
3. Dr. Priscilla Sanabria
4. Dr. Legier Rojas
5. Dr. Juan Amieiro
Veterinarian Consulting
6. Dr. Misty Eaton
7. Thomas Schikorski
8. Mrs. Vivian Valiente , Community Member
9- Dr. Luis Cubano
10- Lic. Betzaida Torres, Supervisor
Animal Resource Center
11- Gerardo Torres
Student Representative
(Class 2016)
ACTION
Approved / ( ) / Approved with modifications / ( ) / Disapproved / ( )
Prof. Zilka Ríos
President of UCC/IACUC / Date (mm/dd/yy)
1