(must be Texas State Faculty member)

Name: First, M. I. Last

E-mail Address

Your immediate supervisor's (Chair or other) e-mail address

Telephone: Office               Laboratory

                      Emergency

University Department

Office Building Room Number

This application is for a   NEW approval, or RENEWAL of an old approval.

If this is a renewal, please enter the previous protocol code. -->

Enter project title here.

If this is a grant-supported project, use the same title as the grant or the appropriate sub-section of the grant.

Prior to selecting the CATEGORY, go to the CATEGORY DESCRIPTIONS & EXAMPLES page and read the explanatory material. Use your "BACK" button to return to this page without losing the data you have already entered.

Check one only - the highest applicable.

Category 1

Category 2

Category 3

Category 4

Category 5

Anticipated: Start Date (m/d/year) End Date (m/d/year)

Note: Your protocol approval will automatically expire after three years even if your end date is more than three years away. If your end date is more than three years away, you will have to reapply for approval.

List all animal species to be used in this project. For each, estimate the total number required and give the source from which the animals will be obtained.

Building or facility where animals will be housed:

Name Room Number

Outline the specific scientific goal(s) and significance of this project in language understandable to a lay-person.

Also include why it is necessary to use animals for this project; why you have chosen the species; and provide the basis for your estimate for the number of animals required.

List the sources of funding for this project. If applicable, include grant titles and identification numbers.

Person responsible for DAILY care of animals (enter even if the same as for PI):

Name: First, M. i. Last

E-mail address:

Telephone: Office Laboratory Emergency

List the names and status (faculty, student, etc.) of all persons working with the animals to be used in this project. For each, indicate their role in the project, previous experience with animals, and prior animal use training.

Each of these individuals, as well as the individual named above as primary care giver, may be required to complete the self-taught training program for animal use.

Give a brief summary of the methods and sources you use to keep current with pertinent literature in your field in order to assure that alternatives to the use of animals have been considered.

You must address each of the following questions separately for each species.

Briefly describe any teaching or experimental protocols, outside of normal husbandry, to be performed on the animals (except description of surgery - see below).

For example: identify all drugs given, including dosage range, routes and frequency of administration; nutritional intervention; social or environmental manipulation; biological samples taken, unusual physical restraining; methods of antibody production; etc.

Specify the expected sequence, frequency and duration of these procedures.

Do you anticipate the animals will experience more than momentary or slight pain or discomfort as a result of your procedures? YES NO

If YES, describe what you will do to relieve this discomfort and assure that no animal experiences undue pain or distress during the course of your procedures.

Include drugs, dosages, nursing care, mechanical devices, humane euthanasia, etc.

Also describe how frequently and how you will monitor your animals to insure they are not experiencing pain or discomfort from your procedures or from unanticipated illness or injury.

not applicable if "no" is selected above

Describe the methods of euthanasia to be used.

If experiments will induce chronic disease, tumors or radiation sickness, describe the criteria for termination of the affected animals.

If the animals are not euthanized at the end of the procedure/project, what will happen to them?

not applicable if animals are euthanized

Will any animal products be used for human consumption? YES    NO

If YES, list any drugs to be given to the animals, and their withdrawal times before consumption. If none, so state.

not applicable if "no" above

Surgery is defined here as a major operative procedure that penetrates and exposes a body cavity or any procedure which produces permanent impairment of physical or physiological functions.

Will ANY surgery be performed on any of the animals? YES NO

If no, skip to #10 below. If yes, complete the following text boxes.

Enter the complete name of the person(s) listed above for question 6 that will be performing surgery.

For each, indicate the type and amount of previous surgical experience.

not applicable if "no" is selected above

Building or facility where surgery will be performed:

Name Room Number

How many animals listed in question 6 will undergo surgery?

Describe anesthetic method used, including all drugs, dosages, routes of administration and supplementation schedules.

not applicable if "no" is selected above

Describe the surgical procedure(s), including a narrative description(s) giving incision site(s), tissue isolation methods, etc. Also estimate the time required to complete the surgery.

Note: aseptic procedures must be used for all survival surgery.

not applicable if "no" is selected above

Will the animals be allowed to recover from surgery? YES NO

If YES, describe the post-surgical or post-anesthetic monitoring and care procedures, including all drugs and dosages. Describe measures designed to alleviate postoperative discomfort.

not applicable if "no" is selected above

Will any animal(s) be allowed to recover from more than one major operative procedure:

YES NO

If YES, provide scientific justification for performing these procedures and list the species and number of animals per year:

not applicable if "no" is selected above  

Note: It is the responsibility of the Project Director to obtain all necessary state and federal permits for work with wild animals and provide copies of those permits to the IACUC. However, possession of such permits does NOT give the Project Director license to use animals without approval of the IACUC. Please see UPPS 02.02.05.

Do you capture wild animals or do experimental manipulations (or procedures) on animals in the wild? YES NO (observation only) .

If no, skip to # 11 below. If yes, complete the following text boxes.

If you capture wild animals, describe how they will be trapped, what types of traps will be used, and how often traps will be checked.

not applicable if "no" is selected above

Describe quarantine procedures and precautions to prevent exposure of humans and other animals to zoonotic diseases.

not applicable if "no" is selected above

If wild animals will be anesthetized and released to the wild, describe anesthetic doses and procedures for assuring that animals are sufficiently recovered from anesthetic to be released.

not applicable if "no" is selected above

Will you be working with non-human primates? YES   NO

If no, skip to the end of the form, below. If yes, complete the following text boxes.

If non-human primates used in you study must be housed individually due to the design of the study, please explain the reasons for that design. Provide enough information for the committee to reach an informed decision.

not applicable if "no" is selected above

If the design of the study requires continuous restraint for longer than 12 hours without the opportunity for exercise, please provide justification for that procedure and include the maximum time the animals will be restrained and the plan for providing unrestrained activity.

not applicable if "no" is selected above