The Ethics Committee for the Treatment of Animals

Faculty of Medicine

Application for change of name, change/extension of study period

For conducting trials in animals under protocol ______

(Please make sure to note the protocol number in the above line)

This form is submitted as an application for one of the following:

1. Change of study name, only for previously approved applications, but that have not yet been performed at all.

2. Change of the study period, only for previously approved applications, but have not yet been performed at all.

3. Extending the study period for previously approved applications, and their conduct has already begun.

The form should be sent to the Ethics Coordinator of the Faculty Ethics Committee as detailed below:

University and hospital researchers submitting ethics applications to the faculty committee in EinKerem: E-mail address: telephone: 02-6758138

Researchers of the Faculty of Natural Sciences and the Department of Psychology in the Faculty of Social Sciences:

Address: Telephone: 02-6586533

Researchers of the Faculty of Agriculture (except the Veterinary School):

Address: Telephone: 08-9489314

Please note the following guidelines:

  1. The form should be submitted in WORD format only, and typed only. Forms submitted in a different format, or in handwriting, or forms not signed by the Principal Investigator, will not be accepted. There is no need for a separate letter of addressing the Committee. The reasons for the application should be entered in section E in this form.
  2. The form should be sent by e-mail with a designated title for the subject, and the protocol number for which the changes request is submitted should be specified in the email title; the table at the end of the form must indicate the exact section that relates to the requested change.
  3. Amendments in light of comments/questions of the committee/examiners will be submitted to the Committee Coordinator on the original application form (this form), in WORD format with the required additions/answers and not by email. The original argument noted in the application form to the committee should not be omitted, but the amendments/answers should be attached to this form in the relevant section.
  4. The official extension will be approved only after an official approval is received by email from the Ethics Committee Coordinator.
  5. Application for additional animals shall not be approved in the Protocol. Study extension exceeding 48 months will not be approved (in NIH grants, study extension exceeding 36 months will not be approved).
  6. Addition of authorized people to work in the research should not be requested on this form; an application to add authorized people in ethics applications should be downloaded from the site and sent by email to the Faculty Ethics Committee Coordinator.
  7. If responses from the Principal Investigator or designee regarding the application submitted in this form are not received within two months, the validity of the application forchange itself shall expire (validity of the application to the Committee) at the end of this period.

Study Detail:

The name of the Principal Investigator: ______

Personal number of the Principal Investigator______

Department ______

Number of the original ethical approval the study received ______

Duration of the study as approved in the original ethical application:

Date of study initiation: ______

Study duration in months: ______

Title of original study in Hebrew ______

______

Title of original study in English ______

Sections of the application submitted to the Committee:

A. The new name of the study (will be completed only in case of a changed to the study name)

In Hebrew ______

______

In English ______

______

B. New study period requested for the above-indicated study (for studies not performed. Explanation detailing the reasons for the application to change the study period should be added in Section D)

C. The duration of time requested for study extension (for studies that have already begun, an explanation should be attached in Section D detailing the reasons for the application to extend the study period)

From- ______(year/month)

To - ______(year/month)

D. Rationale of the application: please detail the reasons for the application submission:

E. The Principal Investigator’s statement in the trial:

I have read the law and the regulations and I undertake to ensure the use of the animals is as detailed in the original application and in this application, according to the law and according to the regulations of the institution.

I undertake to conduct the trial only in the facilities approved by the committee for trials in animals in the institution.

I undertake to contact the Committee for approval of any change in the details in this document.

I have read the guidelines file of the Institution for trials in animals and I undertake to act according to them and according to the instructions of the Council.

I declare that I have not used at all the animals approved for me in the original study application, the number thereof ______(will be filled out only in the event of change in name or change of study period and when no use has been done in animals unilized in the study).

I declare that the requested trial has no appropriate alternative.

I underwent training in conducting experiments with animals and in minimizing the pain caused to them. My authorization number (please specify authorization number):

Those authorized to engage in this trial have also undergone such training prior to their participation in the trial.

The following are the authorized names and their authorization numbers:

Signature of Principal Investigator: ______

Date of submission to the Ethics Committee Coordinator ______

F.Examiners’ comments:

For office use:

Committee’s decision

Name ______

Signature ______

Date of approval/rejection ______

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