ACUC Protocol Form | Albright College

ACUC Protocol Form

Dates Protocol will be in effect: from//to//

This form must be typed; we will not accept handwritten protocols.

Is this protocol related to an external grant or contract application? Yes No

If “Yes,” complete the following:

Agency: Date Submitted://

Grant # :

Project Title: (If project relates to a grant or contract application, give that title; if the project is related to a class, give the course name and number)


Investigator/Instructor: Department:

Campus phone: Emergency phone:

Attending Veterinarian (if necessary):

Phone: Emergency phone:

List all individuals that will handle animals using this protocol (If a class then so specify). Please separate names with commas.

Has the investigator/instructor and all personnel listed above received the appropriate vaccinations (tetanus, rabies)? Yes No

Is it necessary for personnel listed on this protocol to be tested for TB? Yes No

The Principal Investigator/Instructor must be willing to provide appropriate supervision for all persons working on this protocol. In the case of a class, the Instructor must be responsible for training any students in classes involved prior to using animals.

II. Project Description

A. Summary (Write a brief description of your project, using lay terminology):

B. Describe in detail the procedures you will follow. You may do this in either of two ways (check one, and follow the associated instructions):

Accompanying documentation

(If you need more space, please e-mail additional pages to or send printed copies via campus mail to Bryce Brylawski).


By reference to previously published work (provide a complete bibliographic citation here, attach a copy of the work, and describe any variations from the published technique).

(If you need more space, please e-mail additional pages to or send printed copies via campus mail to Bryce Brylawski).

C. Rationale for Involving Animals and the Appropriateness of the Species and Number Used:

In the box below, indicate briefly the short and/or long-term benefits (to humans and/or other animals) of this use of animals for research, teaching or demonstration. Also state briefly why living animals are required for this study, rather than some alternative model.

(If you need more space, please e-mail additional pages to or send printed copies via campus mail to Bryce Brylawski)

D. Do the procedures described in B above, have the potential to inflict more than momentary pain or distress? (this does not include pain caused by injections or other minor procedures) Yes No

If yes please answer the following: I have considered alternatives to procedures that might cause more than momentary or slight pain/distress and I have not found such alternatives. I have used the following methods and sources to search for such alternatives: (Detail methods below)

III. Animal Use

A. List all animal species to be used.

SpeciesNumber1Age2Sex2Weight2Where Housed

1 Individuals using ectotherms need to only approximate numbers.
2 Individuals using fish or other ectotherms need not answer this question.

Is any species threatened or endangered? Yes No

B. Source of animals

If “Donated,” please list source:

If “Purchased,” is the supplier a USDA approved source? Yes No

If “No,” please explain why below:

C. Will surgery be conducted on animals? Yes No

If “Yes,” complete this section:

Non-Recovery Surgery Recovery Surgery Multiple Survival Surgery

If “Multiple Recovery Surgery” is checked, complete section F below.

NameJob/TitleAcademic Rank Location of surgery
Bldg. Room #
Bldg. Room #
Bldg. Room #

D. Will Anesthetic(s), Analgesic(s), or Tranquilizing agents be administered? Yes No

If “Yes,” complete this section.

    Performed by:
SpeciesAgentDoseRouteNameJob/TitleAcademic Rank

E. Will euthanasia be carried out? Yes No

If “Yes,” complete this section.

    Performed by:
SpeciesAgent or ProcedureDoseRouteNameJob/TitleAcademic Rank

If “No,” describe disposition of animal(s) at conclusion of this study.

F. Will special housing, conditioning, diets or other conditions be required? Yes No

If “Yes,” please explain: (Be sure to include where animals will be housed and how care will be handled on weekends and holidays.)

IV. Toxic and Hazardous Substances

A. Will any of the following be used in these experiments?

1. Infectious agents (Fill out a, b)

2. Toxic chemicals or carcinogens (Fill out a, b)

3. Recombinant DNA (Fill out a)

4. Experimental drugs (Fill out a)

5. Adjuvants (Fill out a)

6. Controlled substances (Fill out a, d)

For each category checked above, answer the questions indicated:

a. Identify the substance(s) and completely describe their use, including how will be injected or given to the animal(s):

b. Describe all procedures necessary for personnel and animal safety including biohazardous waste, carcass disposal and cage decontamination:

c. If transplantable tumors or hybridoma cells are to be injected into the animals, have the tissues/cells been tested for inadvertent contamination by viruses or mycoplasma? Yes No

If “Yes,” what was the result?

d. Append a complete list of these substances to this application in the box below, and if their use is not explicitly explained in the materials already provided, explain their use and role in the research.

(If you need more space, please e-mail additional pages to or send printed copies via campus mail to Bryce Brylawski.)

Please provide the DEA license number covering the use of these substances:

To whom (or what entity) is the license issued?  

V. Categories of Animal Experimentation Based Upon Level of Manipulation and Pain:

Checkmark the appropriate letter or letters of categories that apply:

A. Animals will be involved in teaching, research, experiments or tests involving no pain, distress, or use of pain-relieving drugs.

B. Animals will be subject to mild stress only (e.g., food or water deprivation of less than 24 hours for use in behavioral studies such as operant conditioning; physical restraint for less than 30 minutes), and will not be subject to surgery, painful stimuli, or any of the other conditions described below. Procedures described in this protocol have the potential to inflict no more than momentary or slight pain or distress on the animal(s)—-that is, no pain in excess of that caused by injections or other minor procedures such as blood sampling.

C. Animals will have minor procedures performed, blood sampling etc.while anesthetized.

D. Live animals will be humanely killed without any treatments, manipulations, etc. but will be used to obtain tissue, cells, sera, etc.

E. Live animals will have significant manipulations, surgery, etc. performed while anesthetized. The animals will be humanely killed at experiment termination without regaining consciousness.

F. Live animals will receive a painful stimulus of short duration without anesthesia (behavior experiments with flight or avoidance reactions–e.g., shock/reward) resulting in a short-term traumatic response. Other examples in this category are, blood sampling, injections of adjuvants, or drugs, etc.

G. Live animals will have significant manipulations performed, such as surgery, while anesthetized and allowed to recover. Such procedures cause post-anesthetic pain/discomfort resulting from the experiment protocol (e.g., chronic catheters. surgical wounds, implants) which cause a minimum of pain and/or distress. Also included are mild toxic drugs or chemicals, tumor implants (including hybridomas). tethered animals, short-termed physically restrained animals (up to 1 hour), mother/infant separations.

H. Live animals will have significant manipulations or severe discomfort, etc. without benefit of anesthesia, analgesics or tranquilizers. Examples to be included in this category are: toxicity testing, radiation sickness, irritants, burns, trauma, biologic toxins, virulence challenge, prolonged: restrictions of food or water intake, cold exposure, physical restraint or drug addiction. All use of paralytic agents (curare-like drugs) must be included in this category. Describe any abnormal environmental conditions that may be imposed. Describe and justify the use of any physical restrain devices employed longer then 1 hour.

VI. Justifications for Category G Studies and Deviations from

Standard Techniques

Be as detailed as necessary to justify your procedure. Use additional pages if necessary; reference protocol outline number and letter: Describe any steps to be taken to monitor potential or overt pain and/or distress during the course of this study and how such pain or distress will be alleviated.

VII Signatures

(Check One)

Animal Use For Research. I certify that the above statements are true and the protocol stands as the original or is essentially the same as found in the grant application or program/project. The ACUC will be notified of any changes in the proposed project, or personnel, relative to this application, prior to proceeding with any animal experimentation. I will not purchase animals nor proceed with animal experimentation until approval by the ACUC is granted.

Animal Use For Teaching/Demonstration. I certify that the information in this application is essentially the same as contained in the courseoutline and a copy of the laboratory exercises using animals is on file in the ACUC office. The ACUC will be notified of any changes in the proposed project, or personnel, relative to this application, prior to proceeding with any animal experimentation. I will not proceed with animal experimentation until approval by the ACUC is granted.

Department Chairperson’s Statement: I have reviewed this Protocol for Use of Live Vertebrates for Research, Teaching or Demonstration and accept responsibility for its proper administration and enforcement.

Typed name:


A confirmation email will be sent to you by the chair of the ACUC which you will need to print and sign. A physical signature must be on file for all applications.

Signature of Principal Investigator/Course Director Date: _________________________________

Chair’s signature ___________________________________ Date: ________________________

The signature of the Principal Investigator/Course Director indicates that the following have been considered:

1. Alternatives to use of animals.

2. Reduction of pain and stress in animals to the lowest level possible.

3. The proper needs of the animals with respect to housing and care.

4. The lowest number of animals used that will give the appropriate experimental results.

5 Use of the most primitive species that will give the appropriate experimental results.

6. Proper training of all personnel in the care and handling of the species used and in the procedures called for in this protocol before beginning the experiment/teaching or demonstration.

Federal Law requires that members of the ACUC be given adequate time to read and review protocols including any changes or revisions in them.

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