UNIVERSITY OF THE PHILIPPINES LOS BAÑOS
3F UPLB Main Library, UPLB, College, Laguna Philippines 4031 E-mail: iacuc.uplb@up.edu.ph
Institutional Animal Care and Use Committee (IACUC) Form 1
ANIMAL CARE and USE STATEMENT (Protocol Review Form)
I. PROCEDURE(S) and/or TITLE OF RESEARCH STUDY:
II. GENERAL PURPOSE/OBJECTIVE:
III. DURATION or TIMEFRAME:
IV. RESPONSIBLE PERSON 1. Name:
1. Qualification:
V. BACKGROUND and SIGNIFICANCE OF THE PROCEDURE or RESEARCH:
V. DESCRIPTION of METHODOLOGIES/EXPERIMENTAL DESIGN:
A. Type of animal to be used (species and strain/breed):
B. Source of animals (complete name and address of source/facility):
C. Reason/basis for selecting the animal species:
D. Sex and number of animals:
E. Quarantine and acclimation or conditioning process (cite reference):
F. Animal care procedures i. Cage type:
ii. Number of animals per cage:
iii. Cage cleaning method:
iv. Room temperature, humidity, ventilation, and lighting:
v. Animal diet and feeding and watering method:
G. Experimental or animal manipulation method:
i. Description of animal or treatment groups:
ii. Restraint or handling of animals per technical procedure/s to be conducted:
iii. Dosing method to be performed in animals:
iv. Biological sample collection : v. Animal examination procedures:
vi. Anesthesia of animals:
vii. Surgical procedure:
viii. Pre-emptive medications that will be given to animals prior to surgery or technical procedure/s to be performed in animals:
ix. Supportive care and monitoring procedures during and after surgery:
x. Description of measures to prevent possible post-surgical complications:
H. Indicate and describe euthanasia method:
I. Organ sample collection after euthanasia:
J. Is there a non-animal model applicable for the procedure/study? If so, please provide the reason for not using it:
K. Name and qualifications of other personnel (indicate if student)
L. Description of carcass disposal:
M. Reference/s:
VII. DECLARATION BY THE RESPONSIBLE PERSON:
I accept responsibility for assuring that procedures/study will be conducted in accordance with the approved protocol.
I assure that all personnel who will use this protocol and work with animals have received appropriate training/instructions in procedural and handling techniques, and on animal welfare considerations.
I agree to obtain written approval from the Institutional Animal Care and Use Committee (IACUC) of the University of the Philippines Los Baños prior to conducting my study.
I agree to obtain written approval from the Institutional Animal Care and Use Committee (IACUC) of the University of the Philippines Los Baños (UPLB IACUC) prior to making any changes in my approved protocol.
I ALSO AGREE TO PROMPTLY NOTIFY THE IACUC IN WRITING OF ANY EMERGENT PROBLEMS THAT MAY ARISE IN THE COURSE OF THE STUDY, INCLUDING THE OCCURRENCE OF ADVERSE SIDE EFFECTS.
___________________________________ ___________________
Name and Signature of Responsible Person Date Accomplished
2
