ANIMAL SUBJECT APPROVAL FORM
CALIFONIA STATE UNIVERSITY, STANISLAUS
ANIMAL WELFARE COMMITTEE (AWC)
Please answer all questions completely, obtain the necessary signatures, and return original to:
Office of Research and Sponsored Programs MSR 250, One University Circle, Turlock, CA 95382

 Last Name:	First Name:	Telephone:	
 Department:	Fax:	E-mail	
Title of Project:	Funding Agency (if any):	
Proposed start date:	Proposed End date:	Species:	
Please check all boxes that apply to your study:
Type of Protocol:				 	 Type of Project:	
New						Research		Teaching	 
Continuation					Stipend		Pilot

RESEARCH 	CATEGORY

I		             II		           III		           IV		           V	
Research involving plants bacteria, protozoa, invertebrate animals, cold-blooded animals, dead vertebrate animals, live or dead animal tissues or cells	Research on vertebrate animal species that are expected to produce little or no discomfort	Research that involves minor distress or discomfort (short-duration pain) to vertebrate animal species	Research that involves significant but unavoidable distress or discomfort to vertebrate animals species	Research that involve inflicting severe pain near, at, or above the pain tolerance threshold of unanaesthetized, conscious animals	

ANIMAL NUMBERS AND CARE
	I	II	III	IV	V	Bldg/Rm	Arrival mo/d/yr	No. of cages	Animals per cage	Days in care	Reuse/ Euthanise	Total animals/yr.	

													
Species & Strain of Animal	Research category (see above) 		Animal Care
 List source(s) animals, e.g., vendor name, for all animals utilized in study:_________________________

For AWC and Office of Research and Sponsored Programs Use Only:

Approved			Approved as amended			See attached memo

_____________________________________________________________________________________
Chair of Animal Welfare Committee					Date
1.	 DESCRIPTION OF PROJECT
Please provide a non-technical description of the project (research or testing) and its potential value, bearing in mind that the AWC membership includes faculty not engaged in animal research, administrative personnel and community volunteers.  Please use language understandable to the lay person to indicate the overall purpose, goals, and significance of your project.  If this is a duplication study, state why this is necessary.

	
2.	SUPPORTING LITERATURE
The USDA requires you to name two or more databases and references describing the use of the animal model you have selected, if appropriate, and/or to support your justification for the use of animals for your project.  In addition, please indicate whether non-animal models have been developed in your area of research, and if so, describe why they cannot be used to meet your goals.

	
3.	Please indicate whether your procedures with animals will include any of the following:
1)	Adjuvants? (Freund’s or Ribi)	Yes		No
2)	Tumor growth? Such as occurs following a specific treatment and/or injection of tumor cells or monoclonal antibody producing hybridomas. (Please sign agreement with veterinarian)
3) 	Food restriction?		Yes		No	How long?____________________________________
4)	Water restriction?		Yes		No	How long?____________________________________
5)	Blood collection?		Yes		No	
	If yes, indicate volume and frequency in box below.  Please check with veterinarian for guidelines.

	
6)	Injection?	Yes	No	Route and Agent?_________________________________
7)	Restraint?	Yes	No	Type?_________________________
8)	Other invasive procedures?	Yes	No (Explain fully in Question 4)
9) 	Radioactive material?		Yes	No	Radiation Safety Permit #______________________
10)	Biohazardous materials?		Yes	No	Biological Safety Approval?	Yes	No
	(Infectious agents, mutagens, carcinogens, recombinant DNA, etc)
a. For each radioactive or biohazardous agent, list the 1) agent, 2) dose/KG body weight, 3) route of administration, and 4) frequency of administration.  Please list only one agent per line.

	
b. What are the potential health risks to humans and/or animals for each of the agents listed above?  Be specific.

	
c. Where will the animals be housed, and will staff/personnel be exposed to any of the above agents?  Explain.

	
d. Describe special animal care requirements relating to the use of any of the above hazardous materials.  Are there any special containment facility requirements?

	
e. Describe special precautions for animal handlers.

	
f. Describe waste and animal disposal requirements.

	
4.	PROCEDURES TO BE PERFORMED
	For each species, describe the procedures to be performed on live animals, indicating:
a)	the type of procedure (surgery, treatments, injections, behavioral testing, tissue collection, etc.)
b)	the number of procedures to be performed on each animal and what endpoints will be established,
c)	expected effect of each procedure on the animal, including but not necessarily restricted to pain and discomfort,
d)	when the animal will be euthanized during or following the procedures,
e)	drugs administered, including frequency, and list biohazardous materials to be used.

	
5.	NUMBERS
Indicate the number of animals you plan to use for each experimental procedure and justify according to accepted statistical principles.  For breeding protocols, please indicate how many litters might be required to produce adequate numbers for your studies.  In addition, please indicate the maximum number you plan to generate by breeding and whether this number is different than the number you plan to use for experiments.

	
6.	PAIN AND/OR DISCOMFORT
	a. Will the animals be exposed to uncomfortable or painful stimuli or procedures?			Yes	No
	b. Will the pain or discomfort be minimized by the use of anesthetics and/or analgesics?		Yes	No
	(Please note that analgesics must be used following recovery surgery unless sufficient justification is provided).
If the answer to either (a) or (b) is yes, please indicate the following:
	1. Anesthetic to be used	___________________________
	2. Dose			___________________________
	3. Route of Administration	___________________________
	4. Frequency		___________________________
	
c. Are you using neuromuscular blocking agents (NMBA?)	Yes		No
Are you combining NMBA with general anesthesia?		Yes		No
If the answer is yes to either question please specify:
	1. What kind of NMBA?	__________________________
	2. Dose?		__________________________
	3. Frequency?		__________________________
	4. Route of administration	__________________________
	5. Name of anesthetic?	__________________________
	6. Monitoring equipment		BP		EEG		Other____________________

d. In the event that you are unable to relieve pain or suffering, please indicate by your initials below that you agree to  euthanize the animal(s) immediately or call a veterinarian.  
Initials_______________

7.	EUTHANASIA
Euthanasia must be conducted in accordance with the Guidelines on the Panel of Euthanasia of the AVMA.  Please list acceptable method(s) of euthanasia that will be used in this study for each species and check appropriate box(es) below:

	
CO2		Chemical overdose	(List agent, dosage, and route___________________________________________).
Other, describe______________________________________________

8.	TRAINING AND EXPERIENCE WITH THE ANIMALS TO BE USED ON THE PROJECT
Who will perform procedure?		Faculty		Student(s)
Who will supervise procedure?		Faculty		Laboratory Technician
Name of supervisor__________________________________________________________
Please list one or more experts whom the AWC may contact who is familiar with the experimental procedures you are using and might render an opinion regarding the appropriate use of animals for these studies.  Faculty would be appropriate.  Indicate whether or not you would allow this expert to review this form. 

Please list the names of individuals who will come into contact with animals to be used in this project, and indicate their past training and experience with the species to be used and whether they have received any relevant training.  Please note that all employees working with animals must receive appropriate training.  In addition, they are responsible for assuring appropriate training for their staff and students.  

	

9.	EXPERTS
Please list one or more experts whom the AWC may contact who is familiar with the experimental procedures you are using and might render an opinion regarding the appropriate use of animals for these studies.  Faculty would be appropriate.  Indicate whether or not you would allow this expert to review this form.

	

10.	SUMMARY AND QUALIFICATIONS
Please attach a copy of your current resume (or if currently on file in the Office and Research and Sponsored Projects, please indicate).
Approvals:	Signatures certify that adequate space, supervision, maintenance equipment and training in handling this particular species will be available.

_______________________________________________________________________________________________________________
Department Chair 							Date

_______________________________________________________________________________________________________________
Laboratory Technician							Date

Principal Investigator Assurance: I agree and abide by the Guide for the Care and Use of Laboratory Animals, USDA Animal Welfare Regulations (CFR 1985) and Public Health Service Policy on Humane Care and Use of Laboratory Animals (1996) and CSU Stanislaus’ policies governing the use of vertebrate animals for research, testing, teaching or demonstration purposes.  I also certify that the proposed studies do not represent unnecessary duplication of experiments.  I will permit emergency veterinary care to animals showing evidence of pain or illness, if not the desired effect of the above-approved techniques.  The information provided above is accurate to the best of my knowledge.  If the date above regarding category IV and V research should require revision, I will inform the Animal Welfare Committee (AWC).  Appropriate space and funding have been arranged.  The use of alternatives has been considered and found unacceptable at this time.  I declare that all experiments involving live animals will be performed under my direct supervision or under that of another qualified scientist.  Technicians who will be involved have been trained in proper procedures in animal handling and in any administration of analgesics/anesthetics, animal surgery, and euthanasia to be used in this project.

Principal Investigator or Faculty Advisor					Date