To: Austin Health Animal Ethics Committee (AEC)

Austin Health Animal Ethics Committee

APPLICATION FOR DELEGATION OF RESPONSIBLILITY FOR CARE AND WELL-BEING OF EXPERIMENTAL ANIMALS TO AUSTIN HEALTH AEC

Version: #

Date: DD/MM/YYYY

Office Use Only

Date Received: / AEC project Number
Submission Requirements:
One electronic one paper copy submitted to
Research Ethics Officer,
Office for Research
Po Box 5555
145 Studley Rd
Austin Health
Heidelberg, Vic 3084
1. Principal Investigator’s details
Principal Investigator
Department
Institution
Telephone
Email
2. Project Title
3. Project details in LAY terms
4. Project Number
5. Approved period for Project:
From:
To:
5. SPPL Number

To: Austin Health Animal Ethics Committee (AEC)

Please find attached an Animal Ethics Application which has been approved by the ………… AEC to conduct entire or part of the project OR hold animals under Austin Health AEC’s licenced premises.

The Austin Health AEC:

1. Shall act as the delegated AEC to oversee animal housing, animal monitoring and scientific procedures taking place in its premises;

2. Will notify immediately ………. AEC for any unexpected and/or adverse event that may impact on the wellbeing of an animal or any complaint;

3. Has authority to suspend, modify or discontinue any scientific procedure taking place at its premises; (a) that is not in compliance with the ethics approval granted; (b) which as a result of the inspection detects activities that are non-compliant with the Code;

Name & Position (Please Print):
Signature
Date:
Approved by the Executive of the AEC
Chairperson Name (please print) / Chairperson Signature / Date

Note: Project must not commence until signed by Austin Health AEC.

BIORESOURCES FACILITY MANAGER DECLARATION:

The signature of the animal facility manager is required if animals are to be housed in the animal facility.

I confirm that the required animals that the health status of animals is acceptable for entry to the Imaging Facility and can be housed in the animal facility:

BioResources Facility Manager’s Name (Please Print):
BioResources Facility Manager’s Signature
Date:

CHECK LIST:

The Approved Project
A copy is attached? / Yes / No
The approved project uses Austin AEC approved SOPs for all procedures to be performed at Austin Health? / Yes / No
Bureau of Animal Welfare
Copy of Fieldwork Notification form to BAW is attached? / Yes / No
BioResources Facility
Health status of animals approved by Facility Manager? / Yes / No
If long term housing is required, where will the animals be housed and who will care for them at all stages of the project? / Yes / No
Do any genetically modified or cloned animals have phenotypes which require special care? / Yes / No
What criteria will be used to monitor the animals? / Yes / No
What will be done if welfare problems are identified? / Yes / No

Application for delegation of responsibility for care & well-being of experimental animals to Austin Health AEC form version1.1 050913 Page 1