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IACUC V1.Jan@2017
CHECKLIST OF ANIMAL ETHICS APPLICATION, PLEASE TICK (√) IN THE BOX BELOW
Penyelidik Utama:
Principle Researcher/Teacher
No.
DOCUMENTS
APPLICANT
PLEASE TICK
(√)
USM IACUC
PLEASE TICK
(√)
1 Borang Permohonan Kelulusan Etika (Haiwan) Animal Ethics Approval Application Form
2 Cadangan Penyelidikan Research Proposal
3 Tandatangan Penyelidik Utama/Pengajar
Principle Researcher/Teacher signature
4 Tandatangan Penyelidik Bersama
Co-researchers signature
5 Carta Alir
Flow chart
6 Tarikh Memulakan Penyelidikan
Date of the project starting
7 Dokumen-dokumen tambahan yang berkaitan (jika ada)
Additional related documents (if any)
____________________ _________________________ Tarikh:
(Tandatangan Penyelidik) (Tandatangan Penerima) (Date)
(Researcher signature) (Recipient signature)
Jawatankuasa Penjagaan dan Penggunaan Haiwan Institusi USM (JKPPH USM) USM Institutional Animal Care and Use Committee (USM IACUC)
IACUC V1.Jan@2017
USM Institutional Animal Care and Use Committee
NOTE:
1. Please complete the application form in accordance with the Guidelines for the Care and Use of Animals for Scientific Purposes (available at http://www.research.usm.my). Incomplete application will result in the return of the application and delay in the granting of the approval.
2. Attach all relevant documents based on the checklist.
3. Please refer to Appendix A for guideline in fulfilling the form.
4. Application must be word-processed and forwarded to the Chairperson, Institutional Animal Care and Use Committee (IACUC), Health Campus, Universiti Sains Malaysia (USM), 16150 Kubang Kerian, Kelantan.
5. Please submit the SOFTCOPY of application and the checklist from the following email jkpph@usm.my
6. Please submit the signed HARDCOPY to the Secretary, Institutional Animal Care and Use Committee
(IACUC), Division of Research & Innovation, Health Campus, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan. Tel:09-767 2352/2364, Fax:09-767 2351.
NAME OF PRINCIPAL ANIMAL
RESEARCHER/TEACHER
SCHOOL / CENTRE
PROJECT TITLE FOR ANIMAL STUDY
TITLE OF THE GRANT/PHD/MASTER PROJECT (if different from above)
Office Use Only
Proposal Received Date
IACUC File No.
Received by
APPLICATION FOR APPROVAL OF A PROJECT INVOLVING THE USE OF ANIMALS
IACUC V1.Jan@2017
1.2 LIST ALL PERSON INVOLVED IN THE PROJECT (including principal researcher)*
No. Name
School /
Department
Role/ Contribution
I/C /
Passport
No.
Contact
[Email &
H/P]
Signature &
Date
(a)
(b)
(c)
(d)
(e)
*Please ensure that this section is signed by the persons listed *Students involved in the project should be listed
SECTION 1: ADMINISTRATION
1.1 TYPE OF APPLICATION (Please tick [√] one or more)
(a) Research
i Fundamental research
ii Applied research
iii Applied animal model mimicking human disease
iv Applied animal model mimicking the veterinary disease
v Toxicology study
(b) Teaching
(c) Others (Please specify) __________________ (e.g. Breeding, standard
operating procedure)
IACUC V1.Jan@2017
1.3
DURATION OF ANIMAL STUDY Please note that ethical clearance can only be given for a maximum period of 2 years (research) and 3 years (teaching) starting from the approval date
Proposed commencement: Date: Month: Year:
Expected completion: Date: Month: Year:
1.4 ANIMAL(S) REQUESTED
1.4.1
No.
Scientific /
Common Name
Strain Name
(Indicate With an (*) If
Genetically Modified)
No. of male
(Age / Weight)
No. of female
(Age / Weight)
Total
(No.)
Dropout
(%)
1.
2.
3.
Grand Total
1.4.2 Source of animals
Please state the supplier of the animals use for the experiments
1.4.3 Location of animals
Please indicate all the locations at which research using animals will be conducted and housed
IACUC V1.Jan@2017
1.4.4
PERMITS REQUIRED: (Please tick [√]) (YES / NO ) if YES please provide details of appropriate permits held
(a) Holder:
(b) Issuing Agency:
(c) Date of Issue:
(d) Serial No.:
(e) Period of Validity:
1.5
HEALTH AND / OR SAFETY RISK
1.5.1
(a) Does the project involve procedures or agents that might pose a health risk to other animal and / or personnel? (Please tick [√])
(i) Ionizing Radiation :
YES NO
ii) Carcinogen / Teratogen:
YES NO
If Yes, please state the agent: If Yes, please state the agent :
(iii) Pathogenic Organism :
YES NO
(iv) Others :
YES NO
If Yes, please state the agent : If Yes, please state the agent :
(b) If YES to any of the above, please explain the risk and describe the precaution that will be taken.
(c) Describe the facilities available.
IACUC V1.Jan@2017
1.5.2
CLASSIFICATION OF PROJECT
Please tick [√] one or more to indicate the category that best describes all procedures to be carried out
on the animals in the project
A A project requiring animals to be sacrificed for the isolation of embryo and tissue/organ specimen.
B The procedure to be carried out under anaesthesia and the animals to be sacrificed without regaining
consciousness.
C Survival after an intervention, which causes major or prolonged stress (e.g. major surgery and prolonged
restraint).
D Survival after an intervention, which causes minimal stress of short duration (e.g. venepuncture, brief restraint
and skin irritation).
E Animal behavior experiments, including pain assessment.
F Infective or biohazard experiments.
G Genetic modification of animals.
H Toxicity studies.
I Purely breeding projects.
J Production of antisera.
K Blood vessel cannulation
L Other procedures – Please specify.
SECTION 2: JUSTIFICATIONS FOR THE USE OF ANIMALS
IACUC must be satisfied that the use of animals is justified, based on whether the scientific or educational value of the work
outweighs the potential impact on the animal being used
2.1 PROJECT SUMMARY
(a) State the objective of the project
IACUC V1.Jan@2017
(b) Provide a brief background of the study (not more than 250 words).
(c) Provide flowchart of the study and indicate the number of animals to be used in the flowchart
(Attached as an appendix)
(d) Justify the number of animals requested based on statistical calculations, guidelines, published study or other methods
(e) Justify the choice of species / strain of the animals to be used (provide references)
IACUC V1.Jan@2017
(b) State the housing and husbandry for special requirements (if applicable)
Caging or housing
Maximum per cage
Special care
Diet
Environmental enrichment
2.2 ETHICAL IMPLICATION OF THE PROJECT Identify all factors/procedures that may have an impact on an animal’s well being i.e any activities not part of the ordinary husbandry
2.3 REPEATED USE OF ANIMALS, Please tick [√] Have any of the animals been the subject of a previous research or teaching activity?
NO
YES, (if YES, please explain why it is necessary to reuse the animals)
IACUC V1.Jan@2017
SECTION 3: PROJECT DETAIL
Procedures to be carried out on the animals
3.1 ANAESTHESIA
Will anaesthesia be used in the experiment (except for euthanasia) (Please tick [√])
(if YES, please complete the table below)
(a) Please complete the table below for each anaesthetic agent or mixture used (please duplicate the table for
different groups/species/
Agent name
Route of Administration
Dose/volume
Duration (explain in instruction)
Yes
No
(b) Describe how will you monitor recovery from anaesthesia:
(c) Clinical signs to ensure anaesthesia is adequate:
3.2 NEUROMUSCULAR BLOCKING AGENT
Will Neuromuscular Blocking agent be used in the experiment, (Please tick [√])
(if YES, please complete the table below)
Yes
No
Agent
Dose/volume
Route of administration
Justification for use of
neuromuscular blocking agent
IACUC V1.Jan@2017
3.3 SURGERY
(a) Will surgery be performed during the experiment, (Please tick [√]))
(if YES, please complete the table below)
Describe in detail, the surgical procedures to be
carried out on the animals
Name the person identified to perform the
procedure
Is the person familiar with the procedure (Please tick [√])
Trained Yes No
Yes
No
3.4 OTHER INTERVENTIONS
(a) Will other intervention be performed in the experiment, (Please tick [√]))
(if YES, please complete the table below)
Outline the procedure:
State the person identified to perform the procedure:
Yes
No
IACUC V1.Jan@2017
3.5 GENETIC MODIFICATION OF ANIMALS
(a) Does the project involve the use or creation of genetically modified (GM) animals e.g.: transgenic, knockout, or mutant animals (Please tick [√]).
(if YES, please complete the table and section below).
(b) If application for the creation of animals, please state the method/used that will be used. (c) Provide details of the breeding and maintenance of the GM line. Please include personnel and facility involved.
Yes
No
Animal Species & Strain
(Common name)
Name and function of genetic
modified Phenotype of animals
IACUC V1.Jan@2017
SECTION 4: HUSBANDRY & MONITORING
(a) Who will carry out the daily husbandry and monitoring of animal, including weekends and holiday? Provide name and contact number.
(b) Monitoring during and after procedures/interventions; List specific signs to be monitored and their frequency. Please provide the monitoring checklist you will use to record these observations.
SECTION 5: FATE OF THE ANIMALS
(a) What is the maximum period of time that an individual animal or a group of animals will be used in this project?
(b) If animals are to be sacrificed, please fill the table below:
Method
Agents
Route of administration
The dosage used
The person performing the
procedure
(c) What will be the method of disposal of euthanized animals?
(d) If animals are not sacrificed, state what happen to them?
IACUC V1.Jan@2017
SECTION 6: DECRALATION BY PRINCIPAL RESEACHER/TEACHER
I hereby declare that I and co-researcher have the appropriate qualification and experience to perform the procedures
described in this project. I am familiar with the provisions of the USM rules and regulation in animals for the care and use
of Animals for Scientific Purposes; and accept responsibility for the conduct of the experimental procedures detailed
above; in accordance with the requirement of the rules and regulation laid down by the USM Institutional Animal Care and
Use Committee.
I further declare that the procedures described in this project do not constitute unnecessary repetition of work previously
carried out by other research workers or myself, and that each person engaged in this project has been adequately
instructed in, and is competent to perform, procedures that they are carried out. If they are not already skilled in the
procedures, I will be responsible for seeing that they obtain the necessary training in advance, so that each procedure on
an animal will be carried out in the most appropriate manner.
Signature of Principal researcher/teacher :_______________________________ Date : ____________________
Official stamps:
SECTION 7: CERTIFICATION FROM IACUC (CHAIRPERSON / AUTHORISED REPRESENTATIVE)
Name : ____________________
Position : ____________________
Signature : ____________________
Date : ____________________
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