PROTOCOL AMENDMENT

PROTOCOL AMENDMENT

MIDWESTERN STATE UNIVERSITY INSTITUTIONAL ANIMAL CARE AND USE COMMITTEE (IACUC)
Current Protocol Number:
Investigator:
Dept:
Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
TITLE of PROJECT:
Please check the appropriate box(s) and fill in additional information as needed.
1.
New Title(s):
New
2.
Old Title(s):
Old:
3.
CHANGE FUNDING SOURCE TO:
Source:
4.
ADD OR DELETE ANIMAL SPECIES:
Species:
Justification for the additional species.
5.
REQUEST ADDITIONAL ANIMALS:
Species:
Number of additional animals requested:
Total number of animals to be used for the entire project:
Explain why you need additional animals and how you determined/justified the total number of animals requested.
6.
CHANGE A PROCEDURE*:
Procedure:
Please designate whether you are adding, deleting or changing a procedure(s). Indicate species, # animals, treatments and drugs, routes of administration, dosages and schedules of drugs including analgesics and anesthetics, restraining devices, surgical procedures, euthanasia, expected consequences to the animal of the treatments or procedures, and alternatives if more than momentary or slight pain will be produced. Attach additional page(s) if necessary.
7.
*Federal guidelines require that Protocol Amendments include an updated “ALTERNATIVES” keyword search for a change or addition of procedures. A new search using the same keywords from the original protocol may be sufficient.
A. List the sources or databases searched or other sources consulted:
B. List date(s) you conducted the search:
C. List time period covered by the search:
D List the methods or keywords and (or) search strategy used. (Alternative must be a keyword used/listed):
E. List results of the search:
8.
ADD PERSONNEL THAT WILL USE LIVE ANIMALS IN THIS PROJECT:
PERSONNEL THAT WILL USE LIVE ANIMALS:
9.
DELETE PERSONNEL NO LONGER INVOLVED IN THIS PROJECT:
PERSONNEL NO LONGER INVOLVED IN PROJECT:
PI Signature:
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: