ANA G. MÉNDEZ UNIVERSITY SYSTEM

Vice Presidency for Planning and Academic Affairs

Associate Vice Presidency for Sponsored Programs and Compliance

Office of Regulatory Compliance

ANIMAL CARE AND USE COMMITTEE (ACUC)

CERTIFICATION FOR THE USE OF INVERTEBRATES AND VERTEBRATES IN TEACHING (INSTRUCTIONAL) AND RESEARCH WITH INVERTEBRATES

(Incomplete applications will not be revised by ACUC)

For official use only

ACUC No. / Date Approved
(Month/Day/Year)
/ / Expiration Date
(Month/Day/Year)
/ / /

Instructions: This form is used for requesting ACUC exemption from further review your research, teaching or testing using animals. ACUC is responsible for reviewing activities involving all vertebrates and invertebrate used at AGMUS and determining if they are exempt. Fill out the Form in all its parts. If an item does not apply, indicate so by typing N/A. Submit to the Office of Regulatory Compliance one electronic copy and three (3) hard copies of this Form, including references, certificates (e.g. CITI ACUC Certification that apply to the animal species to be used).

I.  PRINCIPAL INVESTIGATOR (PI) INFORMATION
1. Principal Investigator / Last Name First Name / Academic Degree
2. Title of Project
3. Institution, Center or School
4. Department
5. Telephone /Extension /Fax / Telephone Extension Fax
6. Mailing Address
7. Email Address
8. Proposed Research / Faculty Initiated Student Initiated Other:

II. INFORMATION OF THE STUDY OR INSTRUCTIONAL ACTIVITY

Please provide the following information in a non-technical language.
1. What is the objective of this study?
2. Describe and justify the proposed use of animals and the choice of species (200-250 words).
3. Nature of work: / Research with invertebrates Teaching (complete Section V)
Research and Teaching (complete Section V) Field Study
Other, explain:
4. Protocol Type: / Non-invasive Invasive Observational Only (no handling)
5. Description of proposed animal procedures, method of euthanasia or other disposition of animals including special animal care requirements.

III. ANIMAL REQUIREMENTS AND FACILITIES

Common and scientific name (strain if applicable) of animal species
ANIMAL REQUIREMENTS / Year 1
(Year 4 or 7) / Year 2
(Year 5 or 8) / Year 3
(Year 6 or 9)
Number of animals per year provide number of animals used and to be used in the following years
Total of Number of Animals During the Three Years of the Study
Housing location: Lab room number:

Note: The PI is responsible in making housing arrangements with the Facility Manager.

IV. HAZARDOUS AGENTS:

1.  Will hazardous agent’s procedures be used in live animals?
Yes If yes, provide the information requested below No.
Radioisotopes name:
Infectious agents name and biosafety level:
Regulated chemical carcinogens:
Recombinant DNA biosafety level:
2.  Biological waste disposal (if applicable, explain the procedures to be used for the disposal of biological waste):

Note: You should have approval of the Biosafety Committee if you will use any hazardous substances including infectious agents, biohazards, carcinogens, and toxic chemicals used in live animals for this study.

V. INSTRUCTIONAL (TEACHING) USE OF ANIMALS

1. Course name and number:
2. Course dates:
3. Teaching format / Classroom Demonstration Supervised Laboratory Field Trip Other, explain:
4. Course description (educational goals of the course):
5. Purpose of animal demonstration s/ exercises:

VI. ADDITIONAL STAFF

Additional staff that will conduct procedures that involve animals.
List the names of all individuals authorized to conduct procedures involving animals under this proposal, and identify key personnel (e.g., Co-investigator(s), provide their department name, telephone number and E-mail address).
Name / Department / Telephone / E-mail

Note: All the staff must submit their certifications for the care and use of animals. Please go to the instructions for details.

VII. PRINCIPAL INVESTIGATOR AGREEMENT

I certify that the above information is accurate. Only procedures or manipulations approved by the Animal Care and Use Committee will be conducted. I will comply with all pertinent Institutional, town and federal regulations. ACUC approval will be obtained prior to initiating changes in my research or instructional protocol affecting the use and care of animals.
Principal Investigator/ Instructor
Name:
Signature:______Date: /
Month Day Year
School Dean
Name:
Signature:______Date: /
Month Day Year
Certification of Animal Study review by Attending Veterinarian
Name:
Signature:______Date: /
Month Day Year
Certification of Facility Manager of Animal Housing
Name:
Signature:______Date: /
Month Day Year

Please submit all materials to the Office of Regulatory Compliance at your Institution:

UMET (787) 766-1717 ext. 6362/fax (787) 751-3379 E-mail:

UNE (78) 257-7373 ext. 2279 E-mail:

UT 787-743-7979 ext. 4126 E-mail:

Or, E-mail:

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Revised (6/2012) Eng_Ver_01