UNIVERSITY OF WISCONSIN - MADISON REQUEST FOR WAIVER FROM ANIMAL CARE AND USE PROTOCOL REVIEW FOR WILDLIFE OBSERVATIONAL STUDIES IN NATURAL HABITAT
Forms should be typed or in computer-printed format. PLEASE MINIMIZE formatting changes when preparing on computer. Forms can be downloaded via the RARC homepage:
Return completed forms to RARC (396 Enzyme Institute, 1710 University Ave., Madison, WI 53726).
Preferred method of delivery: attachment to e-mail (call 5-2696 or 2-7109 for e-mail address).
INVESTIGATORS: Complete the following information to request a waiver from Animal Care and Use Committee review and approval if your proposed studies consist of simple unobtrusive observation of wild animals in their natural habitat. This waiver will be reviewed administratively. Questions? Call Diane (265-3989), Nancy (890-4563), Debbie (262-7109), or Holly (265-9241).
1.Principal Investigator/Project Director:
Office telephone number: Fax:E-mail Address:
University Department: Office Address:
2.Will your study involve capture and/or invasive procedures on free-ranging animal in natural habitats? Underline or circle your response: NO YES
If yes, stop – a full animal care and use protocol and ACUC approval is required.
3.To the best of your knowledge, will your study materially cause harm to any animals, either intentionally or unintentionally? Underline or circle your response: NO YES
If yes, stop – a full animal care and use protocol and ACUC approval is required.
4.To the best of your knowledge, will your study materially impact the behavior of any animals, either intentionally or unintentionally? Underline or circle your response: NO YES
If yes, stop – a full animal care and use protocol and ACUC approval is required.
5.Please provide the study name, relevant funding source, and one or two sentences describing the interactions among investigators and animals.
INVESTIGATOR SIGNATURE:
To the best of my knowledge, I certify that the information provided in this Request for Waiver is complete and accurate. I understand that any change in the study that introduces direct researcher-animal contact will require review of an animal care and use protocol application and approval of that application by the Animal Care and Use Committee before proceeding. I understand that research animal veterinary consultation is available to me.
I further acknowledge that certain free-ranging species are endangered, threatened, or are of an otherwise special status such that required permits, clearances, or other permission must be obtained prior to proceeding with work. I will verify if target species for this project are listed as threatened, endangered, or of other special status at the state, federal, or international level prior to beginning work. For any such listed species I will abide by all pertinent regulatory requirements, including securing all required permits, clearances, or other permissions prior to the commencement of work. I understand that this waiver does not superceded or substitute for any such permissions.
Signature of PRINCIPAL INVESTIGATOR/PROJECT DIRECTOR*:
* The individual must meet the criteria described in Animal Program Policy 2000-013
Print name: Date:
below for RARC/ACUC use only
I have reviewed the information provided by the Investigator. I certify that the proposed activities consist of wildlife observational studies in which no direct contact with animals is planned, and no direct impact due to deliberate and substantial habitat manipulation is planned or expected. IACUC approval and oversight is not required.
Signature of CHIEF CAMPUS VETERINARIAN:
Print name: Date:
please complete the information below
/ date and initials of consultantPersonal consultation
Phone consultation
Written/email consultation
No consultation
ANNUAL CHECK-IN (effective 1 January 2017)
Date / Who Was Contacted / Status of Project / Told the CCV? / Your InitialsAdditional notes
12/22/2016_HM