University of Texas at Brownsville

The University of Texas Rio Grande Valley
Institutional Animal Care and Use Committee
Amendment / Modification Form
Principal Investigator: Click here to enter text. / Department: Click here to enter text.
Mailing Address: Click here to enter text. / E-Mail Address: Click here to enter text.
Campus Phone Number: Click here to enter text. / Fax Number: Click here to enter text.
Protocol Number: Click here to enter text. / Date: Click here to enter text.
Funded By: Click here to enter text. / Species: Click here to enter text.
Title of Project: Click here to enter text.
A.  Check AMENDMENT(S) requested and provide a reason for the proposed amendment(s) in section “C” below. Sign and submit to the Research Compliance Office at .
☐ Change in personnel. All personnel must complete the training requirements before approval can be granted. Attach training documentation and CV for all personnel being added to the protocol.
☐ Change in title and/or funding source to: Click here to enter text.
☐ Change in source of animals to: Click here to enter text.
B.  Check MODIFICATION(S) requested, provide a brief description in section “C” below and sign. Then revise the currently approved Protocol in Word; highlighting the changes to indicate requested changes and submit both to the Research Compliance Office .
☐ Change in animal strain to: Click here to enter text.
☐ Change in currently approved procedure/manipulations
☐ Change in drugs/compounds administered
☐ Change in duration, frequency, or number of procedures performed on an animal
☐ Increase in number of animals
☐ Change of species to: Click here to enter text.
☐ Addition of procedures/manipulations
☐ Addition of drugs/compounds administered (except for those protocols in which the PI is required to submit this information as it is received from the sponsoring agency: i.e. drug trials)
☐ Change in method of euthanasia (must be AVMA approved )
☐ Other (please explain below): Click here to enter text.
C.  BRIEFLY DESCRIBE REQUESTED CHANGES below and provide details of modifications in the revised Protocol. Click here to enter text.
At the discretion of the IACUC, principal investigators may be required to submit a complete, revised protocol form before approval can be considered. In compliance with federal regulations, neither amendments nor modifications can be applied to work in progress until the IACUC has reviewed and approved the changes. For further information, please contact the IACUC staff at (956) 882-7731.
SIGNATURE OF PI: ______Date: ______
Please sign and submit to the Research Compliance Office at .

IACUC Form 5 - Amendment / ModificationPage 1 of 1Revised: 9/22/15