UST IACUC Animal Care and Use Statement Protocol Review Form

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May 2010

University of Santo Tomas Institutional Animal Care and Use Committee ANIMAL CARE AND USE STATEMENT (Protocol Review Form) UST-IACUC Code: ____________________ BAI Certificate No.: ____________________ (For UST-IACUC) ------------------------------------------------------------------------------------------------------------------------Instructions. (a) Please complete the form by giving all the details asked for. (b) Have the Protocol Review Form SIGNED and DATED by your respective ADVISER/S & DEAN. (c) Submit the accomplished Protocol Review Form to the IACUC Office at the Research Center for the Natural Sciences (Rm. 202 TARC) for review and approval prior the conduct of the scientific work involving animals.

Application Fee Received by: _____________ (PRINT Name & Sign)

RESPONSIBLE PERSON OR PRINCIPAL INVESTIGATOR [PRINT Complete Name, Student Number & Contact Details (cell phone number and email address)]

NAME OF ADVISER/S &/OR CO-ADVISER/S [PRINT Complete Name, College of Affiliation & Contact Details (cell phone number and email address)]

PROCEDURE(S) OR TITLE OF RESEARCH/STUDY:

PURPOSE/OBJECTIVES:

DURATION OR TIME FRAME:

BACKGROUND AND SIGNIFICANCE OF THE PROCEDURE OR RESEARCH:

DESCRIPTION OF METHODOLOGIES/EXPERIMENTAL DESIGN:

UST: S037-00-FO01

RCNAS - UST IACUC Animal Care and Use Statement Protocol Review Form

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UST IACUC Animal Care and Use Statement Protocol Review Form

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May 2010

A. Type of animal used: B. Source of the animals: C. Reason/Basis for selecting the animal species: D. Sex and number of animals: Number of Animals per Treatment (Maximum of 6) Total Number of Animals:

E. Quarantine and/or acclimation or conditioning process Indicate where: ___________________ Duration ___________________ Conditions: F. Animal care procedures 1. Cage Type & Size: Type of Bedding: ___________________ 2. Number of animals per cage 3. Cage cleaning method 4. Room temperature, humidity, ventilation and lighting 5. Animal diet and feeding Feed: ___________________ Water: ___________________

Source: Source:

___________________ ___________________

A. Experimental or animal manipulation methods 1. 2. 3. 4. 5. General description of animal manipulation methods Dosing method Specimen or biological agent Animal examination procedures and frequency of examinations Use of anesthetics i. Where will this be bought? ii. Who will administer? iii. Licensed veterinarian: Name & Licensed no. Surgical procedures Euthanasia Animal Adoption / Disposal
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6. 7. 8.

RCNAS - UST IACUC Animal Care and Use Statement Protocol Review Form

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UST IACUC Animal Care and Use Statement Protocol Review Form

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May 2010

B. Is there a non-animal model applicable for the procedure/study? If so, please provide the reasons for not using it. C. Indicate the names and qualifications of all personnel who will be responsible for conducting the procedures.

RCNAS - UST IACUC Animal Care and Use Statement Protocol Review Form

UST: S037-00-FO01

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UST IACUC Animal Care and Use Statement Protocol Review Form

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May 2010

DECLARATION BY THE RESPONSIBLE PERSON: I ACCEPT RESPONSIBILITY FOR ASSURING THAT THE PROCEDURES/ STUDY WILL BE CONDUCTED IN ACCORDANCE WITH THE APPROVED PROTOCOL. I ASSURE THAT ALL PERSONNEL WHO 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 PRIOR TO MAKING ANY CHANGES AFFECTING MY PROTOCOL. I ALSO AGREE TO PROMPTLY NOTIFY THE IACUC IN WRITING OF ANY EMERGENT PROBLEMS THAT MAY ARISE IN THE COURSE OF THIS STUDY, INCLUDING THE OCCURRENCE OF ADVERSE SIDE EFFECT. Signature over Printed Name of the Responsible Person: ________________________ Principal Investigator Noted by: ___________________________ Adviser _____________________________ Dean, Faculty/College Date: ______________________ Date: ______________________

Date: ______________________

DARIA L. MANALO, DVM Institutional Veterinarian

Date: _____________________

RCNAS - UST IACUC Animal Care and Use Statement Protocol Review Form

UST: S037-00-FO01

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