PI NAME

Form 1 contains following sections; please complete all applicable section(s).

Page 1General information: (for all PIs whose protocol involves biological sample)

[Fill out applicable section below]

Page 2 Section1:Tail Biopsy in mice and rats
Page 3 Section 2:Samples (other than tail) from birds, rats of the genus rattus, and mice of the genus mus.

Page 4 Section 3: Samples from other than birds, rats of the genus rattus, and mice of the genus mus.

** If your laboratory has written Standard Operation Procedures (SOPs) of sample collection, please provide a copy along with this form. The IACUC strongly recommends that each laboratory have SOPs for all of experimental procedures **

GENERAL INFORMATION

  1. Indicate type of sample:

Tail biopsy Blood Serum Tissue Specify :

Body fluids Specify : Genetically modified organisms Specify :
Pathogens Specify : Other Specify :

2. Indicate following information:
Yes No Does your lab have IACUC approved SOPs for this procedure? If “yes”, provide SOP number:

Yes No Will you receive samples from outside of SUNY at Albany? If “yes”, provide specific information of the sample(s):

Yes No Will you sending samples outside of the SUNY at Albany? If “yes”, provide specific information of the sample(s):

Yes No Will you collect samples warm-blooded animals other than birds, rats of the genus rats, and mice of the genus mus? NOTE: If “No”, fill out Section 2. If “yes”, fill out Section3.

  1. Indicate procedures of sample collection:

Tissue/Blood collection(s) in survival procedures
Tissue/Blood collection(s) in non-survival procedures

Other Specify :

  1. Provide a brief description of the purpose of biological sample(s) collection:

SECTION 1: Tail Biopsy in mice and rats

  1. Provide Animal information:

Species / Sex / Age of the collection / Total N of samples will be collected under this protocol
N=
N=
N=
  1. Provide adetailed description of the procedure(s) of the sample collection
    – if you have IACUC approved SOPs, SOP # and skip this section.
  1. Provide following information:
    Yes No Sedation or anesthesia used during the procedure.

If “Yes”, provide following information.

Name of Sedation or anesthesia / Dosage / Route / Schedule of the administration
Discuss the procedures to be followed for checking pain reflexes and effectiveness of sedation or anesthesia

If “No”, provide justification:

  1. Provide schedule (timing of monitoring, frequency of post-biopsy animals) including proceduresforpossible aversive effects (such as infection, bleeding, necrotic tissue) of tail biopsy.

Section 2: Samples (other than tail)

from birds, rats of the genus rattus, and mice of the genus mus.

  1. Provide following information. Duplicate the table as often as required:

Species / Sex / Age of the collection / Total N of samples will be collected under this protocol
Other

2. Provide a detailed description of the procedure(s) of the sample collection
– if you have IACUC approved SOPs, provide SOP # and skip this section.

  1. How frequently will animals be collected samples?

Endpoint of the experiment (terminal)

1 time (non-terminal); indicate time-point of the collection
>2 time (non-terminal); indicate schedule for the collection

  1. Provide following sample information:

Type of Sample / Amount of Sample / Route / Total Numbers of Samples will be corrected
  1. Provide following information:
    Yes No Sedation or anesthesia used during the procedure.

-If “Yes”, provide following information.

Name of Sedation or anesthesia / Dosage / Route / Schedule of the administration
Discuss the procedures to be followed for checking pain reflexes and effectiveness of sedation or anesthesia

- If “No”, provide justification:

6. Provide schedule (timing of monitoring, frequency of post-procedure animals) including proceduresfor possible aversive effects (such as infection, bleeding, necrotic tissue) of tissue collection (if applicable):

Section 3: Samples from other than birds, rats of the genus rattus,

and mice of the genus mus.

If your protocol involves sample corrections other than birds, rats of the genus Rattus and mice of the genus Mus bred, please provide following information.

The Animal Welfare Act requires that the PI must provide written assurance that proposed activities are not unnecessarily duplicating previous experiments and that s/he has considered alternatives in projects causing pain, distress, or discomfort. These requirements do apply to activities of animals other than cold-blooded animals, birds, rats of the genus Rattus and mice of the genus Mus bred for use in research.

[Link:http://www.nal.usda.gov/awic/legislat/usdaleg1.htm]

  1. Provide following information:

Species / Sex / Age of the collection / Total N of samples will be collected under this protocol
Other
  1. Provide a detailed description of the procedure(s) of the sample collection
    – if you have IACUC approved SOPs, provide SOP# and skip this:
  1. Provide following sample information.

Type of Sample / Amount of Sample / Route / Total Numbers of Samples will be corrected
  1. Provide following information:

Yes No Sedation or anesthesia used during the procedure.

- If “Yes”, provide following information.

Name of Sedation or anesthesia / Dosage / Route / Schedule of the administration
Discussion the procedures to be followed checking pain reflexes and effectiveness of sedation or anesthesia

- If “No”, provide justification:

  1. Provide schedule (timing of monitoring, frequency of post-procedure animals) including proceduresfor possible aversive effects (such as infection, bleeding, necrotic tissue) of tissue correction (if applicable):
  1. Provide an explanation and justification of necessity of this sample correction. Include information sources consulted [explanation MUST be in detail]:

FORM 1 // Page 1 of 4