Approval Date: / Length of Approval:
Continuing Review Date: / FULL Committee Review Date:
Project Closure Date: Date in Compliance Database:
Key Personnel Training: Complete Incomplete – Date of Completion:
ISU PROTOCOL REVIEW FORM – ANIMAL BREEDING COLONY
SECTION i: GENERAL INFORMATION
Principal Investigator (PI): / Phone: / Fax:Degrees: / Correspondence Address:
Department: / E-mail Address:
Center/Institute: / College:
PI Level: Faculty Staff Postdoctoral Graduate Student Undergraduate Student
Alternate Contact Person: / Email Address:
Correspondence Address: / Phone:
Title of breeding colony (species / strain of animal):
ASSURANCE
- I certify that the information provided in this application is complete and accurate and consistent with any proposal(s) submitted to external funding agencies.
- I agree to provide proper surveillance of this project to ensure that the rights and welfare of the human subjects or welfare of animal subjects are protected. I will report any problems to the appropriate compliance review committee(s).
- I agree that I will not begin this project until receipt of official approval from all appropriate committee(s).
- I agree that modifications to the originally approved project will not take place without prior review and approval by the appropriate committee(s), and that all activities will be performed in accordance with all applicable federal, state, local and IowaStateUniversity policies.
- I will ensure that all personnel have appropriate training including but not limited to: biosafety principles and techniques, accidental spills, shipping regulations, proper handing of biohazardous materials and waste management, animal welfare regulations, and human subject regulations training.
SIGNATURES
______
Signature of Principal InvestigatorDate
Signature of Department Chair Date
FOR ORA/IACUC USE ONLY:
Project approved (date: )
Project not approved (date: )
______
IACUC Approval Signature Date
FOR ORA/IBC USE ONLY:
Initial action by the IBC :
Project exempt. Date: ______Project referred to the full committee. Date: ______
Project approved. Date: ______Pending further review. Date: ______
Project not approved. Date: ______
Follow-up action by the IBC:
Signature of IBC ChairDate
PLEASE NOTE: Any changes to an approved protocol must be submitted to the appropriate committee(s) before the changes may be implemented.
SECTION II: IACUC INFORMATION
1)YesNo Is this a new colony? If no, please specify previous log number: .
2)What species and strain/breed of animals are included in the colony?
3)Why is it necessary to maintain a colony of these animals?
4)YesNo Will the colony be used by more than one investigator/instructor? If yes, indicate the individuals who will use animals from this colony:
5)YesNo Will animals from the colony be used in more than one project? If yes, list the log numbers of the projects/courses in which these animals will be used:
6)List all individuals who will have contact with the animals:
Name / Duties / CertificationAdd New Row
7)List the individuals who are authorized to approve medical treatment or euthanasia. NOTE: If none of the
individuals listed can be contacted in a timely manner the decision to treat or euthanize animals will be
made by the LAR veterinary staff.
Name / Work # / Home # / E-mail AddressAdd New Row
8)How many breeding animals will be maintained in the colony?
9)What is the source of the animals? (Check all that apply):
Procured through LAR
Bred or reared at ISU (Specify colony, herd, or farm of origin and facility manager)
Captured from wild
Other – Specify:
10)Where would you prefer to have your colony housed?
11)YesNo Will any special housing conditions (e.g., special caging, bedding, environmental requirements, etc.) be necessary? If yes, specify:
12)Describe the mating system to be used and any husbandry procedures which will be performed.
13)How long will breeding animals be maintained in the colony?
14)What criteria will be used for removing animals from the colony?
15)What will be done with surplus animals?
16)How will the colony be monitored?
17)When euthanasia is necessary, describe the method to be used including the agent, dosage, and route of administration. Justify methods not consistent with the recommendations of the American Veterinary Medical Association Panel on Euthanasia.
18)How will carcasses be disposed of following euthanasia?
Rendering
Incineration
Other – Specify:
YesNoWill this project involve the use of transgenic (including knockout)animals? If “yes” is checked, please proceed to Section III, Institutional Biosafety Committee Information.
SECTION III: INSTITUTIONAL BIOSAFETY COMMITTEE INFORMATION
TRANSGENIC ANIMAL INFORMATION
1)Describe how these animals are genetically altered.
2)Please indicate how these animals will be procured. This information is intended to inform the committee if animals will be purchased from a vendor, transferred from another institution or produced here at ISU.
3)Describe the marking system to be used to individually identify all transgenic animals in this project and any resulting offspring.
4)Describe the type and frequency of evaluations to be performed on the animals in this project.
BIOSAFETY CONTAINMENT LEVEL
5)Please check the federal guidelines applicable to the proposed project. The IBC Administrator (,294-5412) can assist you in determining the proper guidelines. All guidelines are also available on the Internet.
For recombinant DNA and/or transgenic animals, refer to the “NIH Guidelines for Research Involving Recombinant DNA Molecules”( Please list the specific safety and/or containment practices to be followed for this project in the box below:
Please indicate proposed biosafety containment level(s) to be used in this project. Refer to the NIH Guidelines for Research Involving Recombinant DNA Molecules (
rDNA Biosafety Level 1 (BL1)
rDNA Biosafety Level 2 (BL2)
rDNA Biosafety Level 3 (BL3)
rDNA Animal Biosafety Level 1 (BL1-N)
rDNA Animal Biosafety Level 2 (BL2-N)
rDNA Animal Biosafety Level 3 (BL3-N)
rDNA Large Scale Biosafety Level 1 (BL1-LS)
rDNA Large Scale Biosafety Level 2 (BL2-LS)
rDNA Large Scale Biosafety Level 3 (BL3-LS)
6) YesNoAre any permits required for this project?
If the appropriate permits have already been obtained, please list the applicable permit numbers:
Permit: Permit: Permit:
Please fax or attach copies of all required permits.
The Department of Environmental Health and Safety (EH&S, 294-5359) can assist you in determining permit requirements and obtaining any necessary permits. Permit requirement information is available on the Internet.
7)Describe the specific decontamination method(s) to be used for all biohazardous waste (except animal carcass disposal) and contaminated equipment. Decontamination methods may include autoclaving, chemical disinfections, etc. If a chemical disinfectant is used, state type and concentration. Please refer to the EH&S Sharps and Biohazardous Waste Policy ( and the Sharps and Biohazardous Waste Disposal Flow Chart ( for assistance
Add New Row
PROCEDURES FOR SAFETY IN ANIMAL FACILITIES
8)Please check all personal protective equipment required in animal facilities:
face shield/goggles/safety glasses (specify):
boots/shoe covers
coveralls/lab coat
rain suit
gloves
head cover
mouth/nose covering (specify type):
other (specify):
9)Please describe any special precautions to be used in the animal facility: (e.g., shower in/out).
STUDY LOCATION INFORMATION
10)Please list the location(s) where the animals will be housed.
BUILDING / ROOM NUMBER IF APPLICABLEAdd New Row
11)List locations of biological safety equipment (for example, clean bench, biosafety cabinet, autoclave). Include most recent certification date for biosafety cabinets. Please enter “failed” if the cabinet did not pass certification testing.
(Required only for biosafety cabinets.)
Add New Row
DISPOSAL
12)Specify how the carcass will be disposed of following euthanasia.
Can be rendered
Must be incinerated (Per ISU EH&S Sharps and Biohazardous Waste Policy, all sheep and goats, and any animals infected with human pathogens must be incinerated.)
Other (specify):
Specify who will dispose of the carcasses.
Disposed of by key personnel
Disposed of by LAR personnel
Collected by Environmental Health and Safety
Other (specify):
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