ANNUAL REVIEW FORM (USDA-COVERED and / or DOD Regulated SPECIES ONLY)

Protocol Number: 0Date Approved: Return this form by:

Principal Investigator: Dr. Phone Number:

Title of Protocol:

Please complete the information requested below and submit a signedPDFversion to .

  1. What is the status of your animal protocol (circle one)? ACTIVE CLOSED

B.If closed, please indicate closure date above, sign and date this form and return to this office immediately.

  1. Indicate any new locations where yourresearch animals are housed: Bldg.______Rm(s).___
  1. Indicate any new locations where animal procedures are performed: Bldg. ______Rm(s). ______
  1. Is there new funding associated with this protocol? Yes___ No___. If yes,complete the New Grant Form.
  1. Are there any changes to the personnel listed onthis protocol? Yes___ No___. Complete the New Personnel Form for any additional personnel. Identify any departed personnel who should be removed from this protocol:
  1. Describe any adverse eventsin the past year:
  1. If you currently hold an exemption toanimal care standards,such as for water scheduling, food restriction for behavioral testing, use of non-pharmaceutical grade substances, or non-social housing, please be advised that the exemption must be renewed annually. If so, please:
  1. Briefly describe the Exemption you hold and whether you intend to continue its use:
  1. Justify the continuation of the exemption:

By signing this form the Principal Investigator certifies that all changes required for this protocol have been/will be submitted to the IACUC and that work has not/will not take place without previous IACUC approval. If new changes are required, please complete an Amendment Form. The investigator certifies that the PI and research staff assigned to this protocol: (1) have read the protocol; (2) are familiar with all of its requirements, and the requirements of all rules, regulations and policies governing the care and use of animals relating to their activities; (3) have had the opportunity to ask questions about it; (4) understand that all animal experimentation not described in the protocol is prohibited in the absence of an approved amendment.

PI Signature: Date:

For IACUC Use Only:
Based upon the information given above, this protocol has been found acceptable for renewal for ONE YEAR
Reviewed by IACUC Member: ______Date: ______

Signature of IACUC Chairman:

Renewal Date

HMA IACUC Annual Renewal Form Page 1 of 1 Revised December 8, 2015