ࡱ> SUR qKbjbj .P_FF\Db=Lddd      $K.udd.Ռ\`80 "  dNddd..ddd dddddddddF O: ܽƵ Institutional Animal Care and Use Committee (IACUC) Application to OBSERVE Vertebrate Animals for Research and/or Teaching (No Contact or Significant Environmental Impact) All research projects or course activities involving the use of live vertebrate animals must be reviewed and approved by the Institutional Animal Care Committee (IACUC) prior to project initiation and/or animal acquisition. This form is appropriate for Observational Studies only. If the study involves bringing live animals into campus facilities, please use the ܽƵ Animal Use Application form that is specific to laboratory or classroom work on campus (link). ܽƵ policy requires that all investigators make an effort to limit the use of vertebrate animals to studies which have scientific merit and/or significant educational value and for which alternative model systems do not exist. For a more complete statement of university policy, please visit the ܽƵ IACUC webpage:  HYPERLINK "http://departments.rwu.edu/mns/" http://departments.rwu.edu/mns/ All faculty, staff and students preparing to submit a protocol to the IACUC committee must first complete the online training course at  HYPERLINK "http://www.citiprogram.org" http://www.citiprogram.org. Please select ܽƵ in the participating institutions drop down box. New users will be prompted to create a user name and password. Select the CITI Recommended Learner group for HSR or Lab/Animal Welfare. This application may be submitted electronically or printed out as hard copy. Electronic submissions will be accepted at  HYPERLINK "mailto:iacuc@rwu.edu" iacuc@rwu.edu provided the principal investigator provides an electronic signature or a signed hard copy of the ܽƵ statement of assurance page (link). For paper submissions, bring the original and 6 copies to the chair of the IACUC committee (link). ALL INVESTIGATORS MUST SIGN THIS STATEMENT OF ASSURANCE: The proposed study involves the use of live vertebrate animals. I understand that as the principal investigator, or course instructor, for the proposed study, I am responsible for: % conducting activities involving live vertebrate animals in accordance with all applicable provisions of the Animal Welfare Act, the U.S. Public Health Service "Guide for the Care and Use of Laboratory Animals" ,applicable USDA regulations and Roger Williams University policies governing use of vertebrate animals for research or teaching purposes. % ensuring that protocols involving live vertebrate animals are submitted to the University Institutional Animal Care and Use Committee for review and approval prior to initiating the study. % reporting any proposed significant changes in the protocol (e.g., change of numbers of animals, change of species, change in investigators etc.). Principal Investigator: _________________________________________ Project Title: ________________________________________________ Animal Species:______________________________________________ Signature of Faculty Investigator:_______________________________ Date:______________ Signature of Student Investigator:_______________________________ Date:______________ Copies of ܽƵ's animal use policies and the U.S.D.A., NIH and other animal use guidelines are available in the IACUC reference library in the Marine and Natural Sciences Building and online from the ܽƵ IACUC website  HYPERLINK "http://www.rwu.edu/iacuc" www.rwu.edu/iacuc . Questions regarding the completion of the application form may be directed to a committee member at iacuc@rwu.edu Protocol Number ____________ (internal use) Date Submitted _________ Faculty Investigator/ Sponsor _______________________________ Home Phone or Cell Phone #_____________________________________ Campus Phone # ____________ Email Address ______________________ Campus Address: ____________________________________________ Protocol Type: % Faculty Research % Student Research % Class Activity Project Title:_________________________________________________ Project Start Date:_____________ Project End Date: ________________ Does this project involve a collaboration with another institution? Y N If yes, attach IACUC approval form from other institution Co-Investigator: ______________________________________________ Phone # _______________ Email Address _________________________ Campus Address: ________________________________________________ Student Investigator: ___________________________________________ Phone # _______________ Email Address_________________________ Local Address: ___________________________________________________ Is this research part of a thesis? Y N Will you receive academic course credit? Y N Will you be paid to work on this project? Y N If yes, source?____________ Animal Species: Common Name: Number of Animals Involved: Permits Required? Y N If yes, attach copies of applicable state or federal permits Permit Agency: Permit Number: Expiration Date: If for an academic class: Course Name: Course Number: Course Instructor(s): Semester(s) and year(s) for which approval is sought: If for a research project: Approximate Start Date: Approximate End Date: Does this project involve field work? Y N If yes, have you established emergency procedures in the event of an injury and are all researchers aware of these procedures? Explain briefly. If yes, have all researchers been apprised of the hazards associated with the plants and animals of the work area? Explain briefly. Geographic Location(s) of study: Will this study involve any alteration of animal habitat? Y N If yes, explain: What is the purpose of this study? Justify the use of the animals chosen. Provide a brief summary of methodology: ܽƵ Institutional Animal Care and Use Committee (IACUC) New Application Status Sheet (Observational Study) Protocol Number: _________________ ^exyz}   k 9 = ]  ⵪yynybZOhrKhrKOJQJhrKOJQJjhrKOJQJUh.th/OJQJh.th"OJQJh.thOJQJh.tOJQJh.thOJQJh^OJQJhhOJQJh.th^5CJOJQJaJh5CJOJQJaJh.th.t5CJOJQJaJh^5CJOJQJaJh.th5CJOJQJaJNOy = > C- hgd" &d P gd" &d P gd"gd"gd2g$a$gd    ; < = >    7 l )7nź~qf[P[h.th7OJQJh.th/OJQJh 4h2gOJQJhLh2g0JOJQJ#j hLh2gOJQJUh0#Wh2gOJQJh2gOJQJjh2gOJQJUh.th2gOJQJh.th"OJQJh"OJQJh1whrK0JOJQJjhrKOJQJU#jh1whrKOJQJUhrKOJQJnox堘yj^jNh"B*CJOJQJaJphh"B*OJQJphh1h"B*OJQJphh"5B*OJQJph h1h"5B*OJQJphh"OJQJhl%OJQJh.thl%OJQJh.th<[OJQJhgOJQJh.th/0JOJQJ#jh.th/OJQJUh.th/OJQJjh.th/OJQJU NPTVZ@AW&'춤옊{j{j[J[ h}b=h"5B*OJQJphh}b=h"B*OJQJph hjlBh"5B*OJQJphhjlBh"B*OJQJphh"5B*OJQJphh"B*OJQJph"h"5B*CJOJQJaJph(h1h"5B*CJOJQJaJphh"B*CJOJQJaJph!h"h"B*OJQJ^Jph%h1h"B*CJOJQJaJphPR?@AGH\] hgd"'FHLM]~5BKZ[crf^Vh7OJQJhl%OJQJh2gB*OJQJphhT0h"0JOJQJ,jhT0h"B*OJQJUph jh"B*OJQJUphh"B*OJQJphh"B*CJOJQJphh}b=h"B*OJQJph h}b=h"5B*OJQJphh">*B*OJQJph h}b=h">*B*OJQJph!Z[dTV\^`BCD @ ^@ `gdYmgd7gd" hgd"cdRTd^`zؼ苃wf\RfhYmOJQJ^Jhl%OJQJ^J hl%hl%CJ$OJQJ^JaJ$hYmhYm5OJQJhlOJQJhv /OJQJh(OJQJhYmh(5OJQJhl%5OJQJhYmhl%5OJQJhYmh75OJQJh"hl%5CJOJQJaJh"h75CJOJQJaJhl%OJQJh7OJQJhYmOJQJABCDVgwʿʄ{ri{r`XPXHh"OJQJhOJQJhlOJQJh75OJQJhk 5OJQJhl5OJQJh^5OJQJhlh75OJQJhOJQJhk OJQJh7OJQJhYmh75OJQJh7hOJQJh7hl%OJQJhv /OJQJhYmOJQJ hl%hl%CJ$OJQJ^JaJ$hl%OJQJhYmhl%OJQJ^JXZ)*ijklmnogd7 &d P &)PWXwx(GIjno}~ƾ־֦֮֝Ʀ|s|ƾkhOoMOJQJh"5OJQJhOoM5OJQJh"hk 5OJQJhlhl5OJQJhZ5OJQJhk OJQJh"hv /5CJOJQJaJh"OJQJhlOJQJh7OJQJhv /OJQJhYmOJQJhYm5OJQJh"hYm5CJOJQJaJ'o = > ? Y Z h i x y !`gdOoMgdl`gdr `gdYm < = > ? W Y Z e w x !!!!D!!!!J"["\"]"k""""#৙|p|ehZ5OJQJ\hOoMhOoMOJQJ\hOoM5OJQJ\ hOoM5\hOoMhOoMOJQJhOoMhOoM5OJQJ\hOoM5OJQJhO)OJQJhOoMhOoM5OJQJhYmOJQJhlhYm5OJQJhv /OJQJhOoMOJQJhlOJQJh"OJQJh2gOJQJ$!!!!F!!!\"]"~"""""##F#a#$a$gdZ ]^gdOoM <^gdOoM!  J#%((]^`gdOoM  J#%((]gdOoMgdOoMgdl##C#D#E#F#G#####HHHHI\I^I`IbIfI~IIIIIIJźސޒ{j`N`Fjh(OJQJ#h#DhZ5CJOJQJ^JaJhZOJQJ^J h#DhZCJOJQJ^JaJhZ5OJQJh#DhZ5OJQJUh#DhZOJQJhZ5CJOJQJaJh.thZ5CJOJQJaJhOoMhO)OJQJhOoMhOoM5OJQJ\hOoMhOoMOJQJhZOJQJhZhOoM5OJQJhOoMhZ5OJQJ\a#######FHHHHHHHHHHII\I^IzI|IIIJJJgdZ ^`gdZ$a$gdZDate Submitted: __________________ Primary Review Date: ______________ Secondary Review Date: ____________ Investigator: Project Title: IACUC Committee Recommendation: % Approved % Resubmit with Revisions (see comments attached) % Rejected (see comments attached) Signature of IACUC Committee Chair: ______________________________ APPROVED PROJECT SIGNATURE PAGE Committee-Approved Protocols must acquire the following signatures before investigators proceed with the approved study: Chair, IACUC: ________________________________ CAO, ܽƵ: ___________________________________ JJ\J]J`JJJK*K+KqKh(5OJQJhZ5OJQJhZOJQJhhZ5OJQJ J]J^J_J`JJJJJJ+K,K-KqK &d P gdZgdZ ,1h/ =!"#$%  DyK  http://departments.rwu.edu/mns/yK Xhttp://departments.rwu.edu/mns/yX;H,]ą'cDyK http://www.citiprogram.orgyK Phttp://www.citiprogram.org/yX;H,]ą'cDyK iacuc@rwu.eduyK *mailto:iacuc@rwu.eduDyK www.rwu.edu/iacucyK 2http://www.rwu.edu/iacuc^ 2 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~_HmH nH sH tH @`@ NormalCJ_HaJmH sH tH DA`D Default Paragraph FontRiR  Table Normal4 l4a (k (No List 6U@6  Hyperlink >*B*phFVF  FollowedHyperlink >*B* phHH 2g Balloon TextCJOJQJ^JaJPK![Content_Types].xmlj0Eжr(΢Iw},-j4 wP-t#bΙ{UTU^hd}㨫)*1P' ^W0)T9<l#$yi};~@(Hu* Dנz/0ǰ $ X3aZ,D0j~3߶b~i>3\`?/[G\!-Rk.sԻ..a濭?PK!֧6 _rels/.relsj0 }Q%v/C/}(h"O = C?hv=Ʌ%[xp{۵_Pѣ<1H0ORBdJE4b$q_6LR7`0̞O,En7Lib/SeеPK!kytheme/theme/themeManager.xml M @}w7c(EbˮCAǠҟ7՛K Y, e.|,H,lxɴIsQ}#Ր ֵ+!,^$j=GW)E+& 8PK!Ptheme/theme/theme1.xmlYOo6w toc'vuر-MniP@I}úama[إ4:lЯGRX^6؊>$ !)O^rC$y@/yH*񄴽)޵߻UDb`}"qۋJחX^)I`nEp)liV[]1M<OP6r=zgbIguSebORD۫qu gZo~ٺlAplxpT0+[}`jzAV2Fi@qv֬5\|ʜ̭NleXdsjcs7f W+Ն7`g ȘJj|h(KD- dXiJ؇(x$( :;˹! 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