IACUC V1.Jan@2017

CHECKLIST OF ANIMAL ETHICS APPLICATION, PLEASE TICK (√) IN THE BOX BELOW

Penyelidik Utama:

Principle Researcher/Teacher

No.

DOCUMENTS

APPLICANT

PLEASE TICK

(√)

USM IACUC

PLEASE TICK

(√)

1 Borang Permohonan Kelulusan Etika (Haiwan) Animal Ethics Approval Application Form

2 Cadangan Penyelidikan Research Proposal

3 Tandatangan Penyelidik Utama/Pengajar

Principle Researcher/Teacher signature

4 Tandatangan Penyelidik Bersama

Co-researchers signature

5 Carta Alir

Flow chart

6 Tarikh Memulakan Penyelidikan

Date of the project starting

7 Dokumen-dokumen tambahan yang berkaitan (jika ada)

Additional related documents (if any)

____________________ _________________________ Tarikh:

(Tandatangan Penyelidik) (Tandatangan Penerima) (Date)

(Researcher signature) (Recipient signature)

Jawatankuasa Penjagaan dan Penggunaan Haiwan Institusi USM (JKPPH USM) USM Institutional Animal Care and Use Committee (USM IACUC)

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USM Institutional Animal Care and Use Committee

NOTE:

1. Please complete the application form in accordance with the Guidelines for the Care and Use of Animals for Scientific Purposes (available at http://www.research.usm.my). Incomplete application will result in the return of the application and delay in the granting of the approval.

2. Attach all relevant documents based on the checklist.

3. Please refer to Appendix A for guideline in fulfilling the form.

4. Application must be word-processed and forwarded to the Chairperson, Institutional Animal Care and Use Committee (IACUC), Health Campus, Universiti Sains Malaysia (USM), 16150 Kubang Kerian, Kelantan.

5. Please submit the SOFTCOPY of application and the checklist from the following email jkpph@usm.my

6. Please submit the signed HARDCOPY to the Secretary, Institutional Animal Care and Use Committee

(IACUC), Division of Research & Innovation, Health Campus, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan. Tel:09-767 2352/2364, Fax:09-767 2351.

NAME OF PRINCIPAL ANIMAL

RESEARCHER/TEACHER

SCHOOL / CENTRE

PROJECT TITLE FOR ANIMAL STUDY

TITLE OF THE GRANT/PHD/MASTER PROJECT (if different from above)

Office Use Only

Proposal Received Date

IACUC File No.

Received by

APPLICATION FOR APPROVAL OF A PROJECT INVOLVING THE USE OF ANIMALS

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1.2 LIST ALL PERSON INVOLVED IN THE PROJECT (including principal researcher)*

No. Name

School /

Department

Role/ Contribution

I/C /

Passport

No.

Contact

[Email &

H/P]

Signature &

Date

(a)

(b)

(c)

(d)

(e)

*Please ensure that this section is signed by the persons listed *Students involved in the project should be listed

SECTION 1: ADMINISTRATION

1.1 TYPE OF APPLICATION (Please tick [√] one or more)

(a) Research

i Fundamental research

ii Applied research

iii Applied animal model mimicking human disease

iv Applied animal model mimicking the veterinary disease

v Toxicology study

(b) Teaching

(c) Others (Please specify) __________________ (e.g. Breeding, standard

operating procedure)

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1.3

DURATION OF ANIMAL STUDY Please note that ethical clearance can only be given for a maximum period of 2 years (research) and 3 years (teaching) starting from the approval date

Proposed commencement: Date: Month: Year:

Expected completion: Date: Month: Year:

1.4 ANIMAL(S) REQUESTED

1.4.1

No.

Scientific /

Common Name

Strain Name

(Indicate With an (*) If

Genetically Modified)

No. of male

(Age / Weight)

No. of female

(Age / Weight)

Total

(No.)

Dropout

(%)

1.

2.

3.

Grand Total

1.4.2 Source of animals

Please state the supplier of the animals use for the experiments

1.4.3 Location of animals

Please indicate all the locations at which research using animals will be conducted and housed

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1.4.4

PERMITS REQUIRED: (Please tick [√]) (YES / NO ) if YES please provide details of appropriate permits held

(a) Holder:

(b) Issuing Agency:

(c) Date of Issue:

(d) Serial No.:

(e) Period of Validity:

1.5

HEALTH AND / OR SAFETY RISK

1.5.1

(a) Does the project involve procedures or agents that might pose a health risk to other animal and / or personnel? (Please tick [√])

(i) Ionizing Radiation :

YES NO

ii) Carcinogen / Teratogen:

YES NO

If Yes, please state the agent: If Yes, please state the agent :

(iii) Pathogenic Organism :

YES NO

(iv) Others :

YES NO

If Yes, please state the agent : If Yes, please state the agent :

(b) If YES to any of the above, please explain the risk and describe the precaution that will be taken.

(c) Describe the facilities available.

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1.5.2

CLASSIFICATION OF PROJECT

Please tick [√] one or more to indicate the category that best describes all procedures to be carried out

on the animals in the project

A A project requiring animals to be sacrificed for the isolation of embryo and tissue/organ specimen.

B The procedure to be carried out under anaesthesia and the animals to be sacrificed without regaining

consciousness.

C Survival after an intervention, which causes major or prolonged stress (e.g. major surgery and prolonged

restraint).

D Survival after an intervention, which causes minimal stress of short duration (e.g. venepuncture, brief restraint

and skin irritation).

E Animal behavior experiments, including pain assessment.

F Infective or biohazard experiments.

G Genetic modification of animals.

H Toxicity studies.

I Purely breeding projects.

J Production of antisera.

K Blood vessel cannulation

L Other procedures – Please specify.

SECTION 2: JUSTIFICATIONS FOR THE USE OF ANIMALS

IACUC must be satisfied that the use of animals is justified, based on whether the scientific or educational value of the work

outweighs the potential impact on the animal being used

2.1 PROJECT SUMMARY

(a) State the objective of the project

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(b) Provide a brief background of the study (not more than 250 words).

(c) Provide flowchart of the study and indicate the number of animals to be used in the flowchart

(Attached as an appendix)

(d) Justify the number of animals requested based on statistical calculations, guidelines, published study or other methods

(e) Justify the choice of species / strain of the animals to be used (provide references)

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(b) State the housing and husbandry for special requirements (if applicable)

Caging or housing

Maximum per cage

Special care

Diet

Environmental enrichment

2.2 ETHICAL IMPLICATION OF THE PROJECT Identify all factors/procedures that may have an impact on an animal’s well being i.e any activities not part of the ordinary husbandry

2.3 REPEATED USE OF ANIMALS, Please tick [√] Have any of the animals been the subject of a previous research or teaching activity?

NO

YES, (if YES, please explain why it is necessary to reuse the animals)

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SECTION 3: PROJECT DETAIL

Procedures to be carried out on the animals

3.1 ANAESTHESIA

Will anaesthesia be used in the experiment (except for euthanasia) (Please tick [√])

(if YES, please complete the table below)

(a) Please complete the table below for each anaesthetic agent or mixture used (please duplicate the table for

different groups/species/

Agent name

Route of Administration

Dose/volume

Duration (explain in instruction)

Yes

No

(b) Describe how will you monitor recovery from anaesthesia:

(c) Clinical signs to ensure anaesthesia is adequate:

3.2 NEUROMUSCULAR BLOCKING AGENT

Will Neuromuscular Blocking agent be used in the experiment, (Please tick [√])

(if YES, please complete the table below)

Yes

No

Agent

Dose/volume

Route of administration

Justification for use of

neuromuscular blocking agent

IACUC V1.Jan@2017

3.3 SURGERY

(a) Will surgery be performed during the experiment, (Please tick [√]))

(if YES, please complete the table below)

Describe in detail, the surgical procedures to be

carried out on the animals

Name the person identified to perform the

procedure

Is the person familiar with the procedure (Please tick [√])

Trained Yes No

Yes

No

3.4 OTHER INTERVENTIONS

(a) Will other intervention be performed in the experiment, (Please tick [√]))

(if YES, please complete the table below)

Outline the procedure:

State the person identified to perform the procedure:

Yes

No

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3.5 GENETIC MODIFICATION OF ANIMALS

(a) Does the project involve the use or creation of genetically modified (GM) animals e.g.: transgenic, knockout, or mutant animals (Please tick [√]).

(if YES, please complete the table and section below).

(b) If application for the creation of animals, please state the method/used that will be used. (c) Provide details of the breeding and maintenance of the GM line. Please include personnel and facility involved.

Yes

No

Animal Species & Strain

(Common name)

Name and function of genetic

modified Phenotype of animals

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SECTION 4: HUSBANDRY & MONITORING

(a) Who will carry out the daily husbandry and monitoring of animal, including weekends and holiday? Provide name and contact number.

(b) Monitoring during and after procedures/interventions; List specific signs to be monitored and their frequency. Please provide the monitoring checklist you will use to record these observations.

SECTION 5: FATE OF THE ANIMALS

(a) What is the maximum period of time that an individual animal or a group of animals will be used in this project?

(b) If animals are to be sacrificed, please fill the table below:

Method

Agents

Route of administration

The dosage used

The person performing the

procedure

(c) What will be the method of disposal of euthanized animals?

(d) If animals are not sacrificed, state what happen to them?

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SECTION 6: DECRALATION BY PRINCIPAL RESEACHER/TEACHER

I hereby declare that I and co-researcher have the appropriate qualification and experience to perform the procedures

described in this project. I am familiar with the provisions of the USM rules and regulation in animals for the care and use

of Animals for Scientific Purposes; and accept responsibility for the conduct of the experimental procedures detailed

above; in accordance with the requirement of the rules and regulation laid down by the USM Institutional Animal Care and

Use Committee.

I further declare that the procedures described in this project do not constitute unnecessary repetition of work previously

carried out by other research workers or myself, and that each person engaged in this project has been adequately

instructed in, and is competent to perform, procedures that they are carried out. If they are not already skilled in the

procedures, I will be responsible for seeing that they obtain the necessary training in advance, so that each procedure on

an animal will be carried out in the most appropriate manner.

Signature of Principal researcher/teacher :_______________________________ Date : ____________________

Official stamps:

SECTION 7: CERTIFICATION FROM IACUC (CHAIRPERSON / AUTHORISED REPRESENTATIVE)

Name : ____________________

Position : ____________________

Signature : ____________________

Date : ____________________