Modification Request Form to Add Personnel

This form is to be used to add personnel to current AEC protocols (including Euthanasia for Tissue). Please fill in all applicable fields, print and sign the form and send to the AEC Secretary on your campus.

Please note that multiple people can be added at one time or one person can be added to multiple protocols. Simply copy the appropriate section as many times as required for your additions.

Ensure that personnel signing this application have read and understood the declaration and the protocol to which they are being added.

SECTION A (All fields must be filled in)
AEC Number:
AEC Title:
Principal Investigator:
Department
SECTION B(Details of new personnel)
Full Name:
Username:
Department:
Email Address:
Work Phone:
Lab Phone:
Emergency Phone:
Status: / AcademicExtramuralLab Technician
Post-DocAssist Research Fellow/Research Assist
Student
What is the contribution of the individual to the study? Please indicate which manipulations are being performed (i.e. surgery, injections, etc.)
Work History: Please explain what qualifies this person for the procedures described in the protocol including any in-vitro work (a list of degrees awarded may be relevant but is NOT sufficient).
Training Provider:Please specify the proposed training procedures and the name of the training provider.
Please indicate if this person will be picking up/administering PAR? Yes No
Please indicate if you have received Module Training from the Animal Welfare Office Yes No
If Yes, please specify which Module(s): 1 Date:2 Date:3 Date:
AEC Number:

Declaration by Personnel Using Animals

I hereby certify and undertake that:
  1. I have read, understood,and have access to the protocol to which I am being added.
  2. I will comply with the conditions for the use of animals in research, testing and teaching as defined in the New Zealand Animal Welfare Act 1999 and the controls on Prescription Animal Remedies (PAR) as defined in the Agricultural Compounds & Veterinary Medicines Act 1997.
  3. I will comply with the University policies for the purchase and management of PAR (if applicable to this protocol).
  4. I confirm that I will use only the Prescription Animal Remedies listed in the named AECprotocol.
  5. I confirm that any additional PAR proposed for use in the AEC protocol as defined in the present IDAO application will first be approved by the institutional veterinarian in accordance with University policies and procedures.
  6. I have read the University of Otago's Code of Ethical Conduct for the Manipulation of Animals and agree to abide by the conditions therein. Failure to comply will result in withdrawal of my approval to use animals.

Principal Investigator

Print Name / Signature / Date

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Modification Request Form to Add Personnel

New Personnel

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Modification Request to Add Personnel

Print Name / Signature / Date

Head of Department (if required by Departmental policy)

Print Name / Signature / Date

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