Animal Care Committee

Application for Renewal or Amendment

Use this form if there has been a change from the original protocol or if the original protocol needs to be renewed. Please fill in all applicable fields and attach the original approved protocol for reference. If the Animal Care Committee determines that major changes of the protocol are requested, a new protocol will be required.

  1. GENERAL INFORMATION

Title: Click here to enter text.
Protocol Number: Click here to enter text.
Original Approval Date: Click here to enter a date.
Principal Investigator or Instructor: Click here to enter text.
Reason for renewal/amendment:
☐Annual Renewal☐Change in protocol or personnel
Explain reason for change:
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If renewal, provide a start date and end date:
Start Date: Click here to enter a date.End Date: Click here to enter a date.
  1. QUESTIONS 1-14: PLEASE INDICATE WHETHER OR NOT EACH OF THESE SPECIFIC ISSUES APPLIES TO YOUR APPLICATION; AND SUPPLY THE REQUESTED INFORMATION, IF APPLICABLE.

1. Are there changes in personnel (deleting and/or adding faculty, staff, graduate studies, attending veterinarian, etc.)?
Note: The Principal Investigator is responsible for ensuring that suitable training has occurred before personnel actively participate in the research project.
☐Yes (complete the tables below)☐No (proceed to question 3)
2. Name associates directly involved in the care and use of animals in this project.If this is a Directed Studies Project, clearly indicate the student doing the study.
Co-Investigators
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Staff and Students
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3. Training & Qualifications of all Co-Investigators, staff and students:
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4. Emergency Personnel:
(at least 2 people, available evenings and weekends)
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5. Has training been completed for new personnel? If no, when is the anticipated date of completion?
☐Yes☐NoClick here to enter a date.
6. Are the type and/or number of animals to be used the same as in your last protocol? If no, please describe relevant changes and provide rationale.
☐Yes☐No
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7. Provide amended information.
Species
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8. Indicate the number of animals used in the preceding year:
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9.Indicate the number of animals going to be used for the upcoming year and provide justification:
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10. Has there been changes regarding the source of the animals?
☐Yes (complete the table below)☐No (proceed to question 11)
Species
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Phone number
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11. Have you advised the Animal Care Technician as to any amended housing requirements and the anticipated date of arrival?
☐Yes☐No
12. Are there changes to be made to the procedures?
☐Yes (complete table A & B below)☐No (proceed to question 13)
TABLE A – PROCEDURES
Identify the individuals who will perform each procedure, and how they are qualified to do so. If applicable, describe field study protocols in detail. Reference can be made to subsequent sections. Use additional pages if necessary.
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Describe the purpose of animal use (PAU), as defined in the CCAC Interpretation bulletin no. 1-1: Animal Use Date Form
☐PAU 1 – Studies of a fundamental nature in sciences relating to essential structure or function
☐PAU 2 – Studies for medical purposes, including veterinary medicine, that relate to human or animal diseases or disorders
☐PAU 3 – Studies for regulatory testing of products for the protection of humans, animals, or the environment
☐PAU 4 – Studies for the development of products or appliances for human or veterinary medicine
☐PAU 5 – Education and training of individuals in post-secondary institutions or facilities
Is the work or procedures acute or chronic?
☐Acute☐Chronic
If the Category of Invasiveness has changed, please indicate the Category of Invasiveness as defined in the CCAC policy statements on categories of invasiveness in animal experiments (please see document for examples):
☐Experiments or procedures on most invertebrates or on live isolates
☐Experiments or procedures which cause little or no discomfort or stress
☐Experiments or procedures which cause minor stress or pain of short duration
☐Experiments or procedures which cause moderate to severe distress or discomfort
☐Experiments or procedures which cause severe pain near, at, or above the pain tolerance threshold of anaesthetized conscious animals
TABLE B – DRUGS AND CHEMICALS
Give details of the anaesthetic regime to be used. Indicate dosages and routes of administration for each species. Name the person(s) who will administer and monitor the anaesthetic:
Drug / Dosage / Route / Individual
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Indicate care which may be required for each species. Give dosages, frequency, routes of administration and duration. Name the person(s) who will administer the care for each category below:
Drug / Dosage / Route / Individual
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If nursing or special care is required, please indicate who will provide it:
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List any other drugs and chemicals that may be used. Give dosages, frequency, routes of administration, and duration. Name the person(s) who will administer the care for each category below:
Drug / Dosage / Route / Individual
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13. Please provide a brief rationale for the changes noted in the above tables.
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14. Has the experimental and/or animal use endpoint of the project changed?
☐Yes (provide the details)☐No
15. Please describe any changes in the disposal of dead animals
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16. Are there other changes to your protocol not captured in other questions? E.g. funding sources, accommodations, lay summary, emergency veterinary care, etc.?
☐Yes (provide the details and attach relevant portions of the grant, if applicable
☐No
17. Were the any concerns over the past renewal term, including unexpected mortality, or termination of animals?
☐Yes a) Provide the details
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b) Describe the changes made to prevent recurrences
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☐No
C. PROGRESS REPORT
a) How many animals were used in the previous year?
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b) Were there any amendments to the original protocol? Describe.
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c) Describe any complications encountered relative to animal use (unpredicted outcomes, animal pain, distress or mortality)
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d) Describe any complications encountered or refinements made relative to protecting animals from pain, distress or mortality.
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e) Describe the adequacy of the endpoints for the protocol and describe any endpoints that were applied
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f) Summarize any progress with respect to how the three R’s (replacement, reduction, refinement) were applied to your protocol
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  1. DECLARATION – must be attached to application

These amendments and/or time extension to the Animal Use Protocol indicated above, accurately describe the procedures that will be done.
Signed ______Date ______
(Researcher/Instructor)

Partially adapted from Acadia University with permission