Johns Hopkins University s5

Johns Hopkins University Animal Care and Use Committee

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**Below for ACUC Use**

CHANGE IN PERSONNEL

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Date Received:

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AMENDMENT REQUEST FORM

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Expiration Date:

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Protocol Number: / c Logged / c Database
Protocol Title:
Principal Investigator:
Department: / School:
Building: / Room: / Campus:
Office Phone: / Fax: / E-mail:

Please use this form to add personnel except Principal Investigator. Please e-mail, fax (443-287-3747), mail or bring a signed copy of this form to the ACUC Office, Reed Hall, room B122.

Forms will be processed administratively as received. They are not subject to a full committee review.

Each individual must complete the online training course, ““Animal Care and Use” found online in the courses under myLearning at http://www.hopkinsmedicine.org/interactive_learning/my_learning/ or from a link under “Quick Links” found on our website at www.jhu.edu/animalcare before the individual will be approved to handle animals under this protocol.

***This form MUST be accompanied by the certificate of enrollment in the Animal Exposure Surveillance Program (AESP) for each person to be added, in order for the amendment to be processed (call 410-955-6211 for information)***

1) I understand that the personnel to be added must not begin work on this protocol until approval is received from the Animal Care and Use Committee.

2) The personnel to be added are fully qualified to perform animal related duties under this protocol or will be trained and supervised by the individual named (in Item 4 above) and will be given a copy of the protocol.

PI Signature: Date:

IACUC Authorized Approval: Date:

Role: /

**NEW** Primary Co-investigator (person delegated authority when PI is unavailable)

Last Name: / First Name: / M. Initial:
Department: / School:
Building: / Room: / Campus:
Office Phone: / Fax: / E-mail:
JHU appointment or job title:
Degree(s) held:
Specialty and/or major for each degree listed above:
List procedures this person will be performing (can state “all”):
Describe the person’s experience with the procedures and the species in this protocol:
If training and/or supervision of this person is necessary, who will be providing it?
ACUC office use: AESP __ OLT __
Role: / c Co-Investigator c Fellow c Student c Faculty c Staff c Outside Collaborator (Check all that apply.)
Last Name: / First Name: / M. Initial:
Department: / Phone Number:
JHU Address: / Bldg & Room:
Email Address:
JHU appointment or job title:
Degree(s) held:
Specialty and/or major for each degree listed above:
List procedures this person will be performing (can state “all”):
Describe the person’s experience with the procedures and the species in this protocol:
If training and/or supervision of this person is necessary, who will be providing it?
ACUC office use: AESP __ OLT __
Role: / c Co-Investigator c Fellow c Student c Faculty c Staff c Outside Collaborator (Check all that apply.)
Last Name: / First Name: / M. Initial:
Department: / Phone Number:
JHU Address: / Bldg & Room:
Email Address:
JHU appointment or job title:
Degree(s) held:
Specialty and/or major for each degree listed above:
List procedures this person will be performing (can state “all”):
Describe the person’s experience with the procedures and the species in this protocol:
If training and/or supervision of this person is necessary, who will be providing it?
ACUC office use: AESP __ OLT __
Role: / c Co-Investigator c Fellow c Student c Faculty c Staff c Outside Collaborator (Check all that apply.)
Last Name: / First Name: / M. Initial:
Department: / Phone Number:
JHU Address: / Bldg & Room:
Email Address:
JHU appointment or job title:
Degree(s) held:
Specialty and/or major for each degree listed above:
List procedures this person will be performing (can state “all”):
Describe the person’s experience with the procedures and the species in this protocol:
If training and/or supervision of this person is necessary, who will be providing it?
ACUC office use: AESP __ OLT __

Revised 07/17

Personnel Amendment Form, Page 2