Georgia State University s1

GEORGIA STATE UNIVERSITY

INSTITUTIONAL ANIMAL CARE AND USE COMMITTEE

Personnel Amendment Form for Animal Protocols

(revised 11/7/2014)

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Protocol Number:

Principal Investigator:

Protocol Title:

Animal Type and Number Approved:

Original Approval Date:

Complete the information below for each individual for the above protocol (copy and paste for as many individuals as needed). NOTE: Please use one form per protocol.

If training has not been completed, visit Georgia State IACUC Home Page and click on “How to Enroll in and Use the AALAS Learning Library”. Complete the Required Education SECTION prior to submitting this protocol application.

All employees of Georgia State University who work with vertebrate animals must enroll in the Medical Monitoring Program for Vertebrate Animal Exposure. To enroll chick on the following link: https://mygsu.sharepoint.com/sites/research/mmpvae/SitePages/Home.aspx

Name:

Phone and Location:

Action: (Add or Remove):

Status (Co-PI, post-doc, student, staff):

Experience: (Have staff mastered competence with the procedures they will perform? If an individual is in need of training on a procedure, indicate who will provide training):

Procedures this person will do on animals:

Has GSU Training been completed? ÿ Yes ÿ No

Has this individual been enrolled in the Medical Monitoring Program for Vertebrate Animal Users? ÿ Yes ÿ No

Name:

Phone and Location:

Action: (Add or Remove):

Status (Co-PI, post-doc, student, staff):

Experience: (Have staff mastered competence with the procedures they will perform? If an individual is in need of training on a procedure, indicate who will provide training):

Procedures this person will do on animals:

Has GSU Training been completed? ÿ Yes ÿ No

Has this individual been enrolled in the Medical Monitoring Program for Vertebrate Animal Users? ÿ Yes ÿ No

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Investigator’s Signature Date

PLEASE RETURN THIS FORM TO:

IACUC Compliance Officer / Georgia State University / Office of Research Integrity / 232 Alumni Hall / Atlanta, GA 30303 e-mail:

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Approved: IACUC Chair Signature Date