INSTITUTIONAL ANIMAL CARE AND USE COMMITTEE [IACUC] – INCIDENT REPORT FORM
The Incident Report Form is used for unexpected incidents, adverse events, and noncompliance. Submit the completed form and relevant documentation to .
Use this form to report:
· Any unexpected event or outcome that resulted in an animal welfare issue (death, disease, distress), or a human health or safety issue (zoonotic disease or exposure, injuries)
· Any noncompliance associated with OSU’s Animal Care and Use Program
· Any animal welfare concern associated with OSU’s Animal Care and Use Program
Name: Contact information:
Do not complete if you wish to remain anonymous
Principal Investigator: E-mail: Phone: Incident Report
Department:
ACUP #: Title:
1. Type of Incident (check all that apply):Unexpected animal morbidity or mortality Unexpected human health event
Noncompliance with ACUP, Policy, Program
Facility or life support system event Animal Welfare Concern Report
2. Incident Date(s):
Species/group/type of animals involved Facility/Room/Location:
Number of animals affected: Select % of animals affected within group: <select %> <1 - 5% 5 - 15% 15 - 30% 30 - 50% 50 - 75% 75 - 100%
Effect on animals: <select> No animals affected in event Animals affected, no pain or distress Mild & transient pain or distress Animals found deceased Other - please describe in summary below Pain/distress identified quickly, relieved Pain/distress experienced, relieved Pain/distress experienced, not relieved
3. Persons involved in incident(s):
Training & related experience of persons involved:
4. Summary of incident:
5. Cause of incident:
6. Outcome of incident:
7. Immediate Management of the incident:
8. Management Plan moving forward:
9. Changes necessitated by incident: <select> Amendment to ACUP Other action required No action required
Please describe:COMPLETION BY IACUC OFFICE:
Aug 2015
Date and Description – Initial Review:
Action:
Date and Description – Additional Review:
Action:
Aug 2015