IACUC#

Institutional Animal Care and Use Committee

IACUC Research Application Revised 5/23/2019

INSTRUCTIONS: ALWAYS download the latest version, and then save this form before completing it. DO NOT type into the gray shaded areas. Add lines to tables as needed. To check a box, point the cursor to the box and left click.

Submit application by emailing the completed application in WORD format along with all supporting documents to: IACUCoffice@lsuhsc.edu. Personnel submitting on behalf of the PI must cc the PI on the email for IACUC acceptance of the application. Paper submission will not be accepted.

If you have a problem using the form, email the IACUCoffice@lsuhsc.edu or call 504-568-4970. Links to helpful resources:LSUHSC-NO Division of Animal Care: https:/ /intranet .lsuhsc.edu/animalcare/ Animal Welfare Act: http://www.nal.usda.gov/awic/legislat/usdaleg1.htm Guide for the Care and Use of Laboratory Animals: http://grants.nih.gov/grants/olaw/references/phspol.htm

Electronic Submission Date:

Check type of application ☐ Initial ☐ 3-year renewal If 3-year renewal, enter previous IACUC#

PI name (faculty or staff)

Degree

Position DepartmentEmail address Office phoneCell/after hours Lab phone

If the above PI is serving as a mentor for this project, provide co-PI’s information.Name DegreePosition DepartmentEmail address Telephone

If desired, designate a person whom Animal Care staff should initially contact for animal welfare issues within the vivarium before contacting you.Name Office/lab phoneEmail Cell phone

NOTE: Your emergency contact information is maintained by the DOAC and IACUC office. Report any changes to your or your alternate’s contact information to the IACUC Coordinator.

Project title

1. Other required institutional oversight

LSUHSC-NO IBC approval required? ☐ Approved ☐ Pending ☐ No IBC#LSUHSC-NO radiochemical certification required?

☐ Approved ☐ Pending ☐ No Cert#

LSUHSC-NO IRB approval required? ☐ Approved ☐ Pending ☐ No IRB#List any non-LSUHSC-NO institutional oversight and approval date.

Institutional project #

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2. Estimate the time frame of this project.

Approximate start date Duration

3. List all funding sources.Name of department, agency, organization, foundation, corporation

Grant #, if applicableAward period dates or pending?If award to another individual, provide PI name

Name of department, agency, organization, foundation, corporation

Grant #, if applicableAward period dates or pending?If award to another individual, provide PI name

If this project is or will be associated with a grant, a congruency check may be required by the funding agency. List and provide a brief explanation for any discrepancies between what is described in the grant and this application.☐ There is no association with a federal grant or any other organization that requires a congruency check.☐ There are no discrepancies between the grant and this IACUC application. ☐ The following differences between the grant and this IACUC application are explained below.

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4. List all participants in this project in the table; add rows as needed. The PI is responsible for ensuring that all research personnel participating in this project have completed all required institutional training and specific training to perform activities listed below. To gain access to DOAC facilities, individuals must complete DOAC Orientation and Training Seminar. Individuals can retrieve or print their certification dates from KDS: KDS on-line training and CITI: https://www.citiprogram.org/

First & last name, degree

# years of experience with species being used

List activities trained/experienced to perform

Has DOAC access?

Date of KDS Animal Care Occ Health (mm/dd/yy)

Date of CITI training (mm/dd/yy)

5. Identify the species to be used in this project. ☐ Mouse ☐ Rat ☐ Rabbit ☐ Pig ☐ Primate ☐ Bird ☐ Frog ☐ Cat☐ Other, specify

6. If this is a renewal application, briefly describe what has been accomplished thus far. Indicate how many animals (by species) have been used; do not include these numbers in the new animal numbers being requested in this renewal application. Limit to 200 words or less.

[Type here]

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7. In NON-TECHNICAL LANGUAGE, briefly summarize the purpose and how this study may benefit human or animal health or advance the scientific understanding of biological processes. Define all acronyms, limit summary to less than 250 words, and check for readability level not higher than grade 12 (high school) elevation on https://storytoolz.com/ or similar algorithms.

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8. In NON-TECHNICAL LANGUAGE, summarize by species what will be done to the animals. Define all acronyms and limit explanation to less than 150 words.

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9.Experimental Design

9a. Provide a flow chart, diagram, timeline, etc. to illustrate the entire experimental progression of the project beginning with the entry of an animal into the experiment to the endpoint of the study. See webpage for timeline example: https://www.lsuhsc.edu/administration/academic/ors/iacuc.aspx

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9b. Describe the distribution of the number of animals requested throughout the study (show group assignments according to experimental variable or list each animal according to use). All animals must be represented and must be consistent with the total number of animals requested in the Table 10.

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9c. Provide a detailed narrative of the proposed use of the animals that will allow the IACUC to understand the experimental course of this project. Provide quantitative and qualitative information where applicable depending on study design. Describe in detail all procedures and/or experiments to be used on the animals. For surgical procedures, just reference the name of the surgery and provide details of the procedure by completing Addendum 1: Surgical Procedure Form.

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10. Provide the total number of animals of each species needed for the duration of this protocol approval period. Indicate the appropriate USDA category under which the experiments fall. Count the animal only once. If an animal is subject to multiple categories, count the animal in the highest category.

USDA Category C: No pain, distress or use of pain-relieving drugs (e.g., studies, experiments, tests or procedures where animals do not experience pain or distress but may have only transitory discomfort such as venipuncture, injection, tattooing. Tumor and CFA studies are not eligible). USDA Category D: Painful or distressful with use of analgesia, anesthesia, sedatives or tranquilizers (e.g., painful or stressful experiment, tests or procedures that are conducted with the use of appropriate drugs that will prevent pain or distress; also includes procedures performed on anesthetized animals that are not allowed to regain consciousness).USDA Category E: Painful or distressful without pain and stress relieving measures. Prior consultation with the veterinarian is required (e.g., painful and stressful procedures performed without the use of appropriate analgesics,

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anesthetics and sedative drugs or other measures to prevent and relieve pain or distress; painful and stressful procedures not amenable to relief by therapeutic measures).

Species/Strain

Check if any are

genetically modified

Gender: M=male F=female M/F=both

Age range # animals

category C # animals

category D# animals category E

Total # animals(C+D+E)

☐☐☐☐☐☐

For multiple strains of a species, recap the total animals requested by each species.Species: Total # for this species:Species: Total # for this species:

10b. If pain category E is indicated, veterinarian consult is required prior to submission of this application. Name of veterinarian: Date of consult:

(mm/dd/yyyy)Provide justification for each procedure/experiment when not using appropriate analgesics, anesthetics, sedatives, or other measures to prevent pain or distress. This information will be included in the USDA annual report for covered species.

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11. Indicate the source(s) of the animals.

SpeciesCommercial vendor(s) ☐ ☐ ☐IACUC protocol # If not you, identify PI of the IACUC protocolIdentify other source(s) and indicate the circumstances in which the animals will arrive at LSUHSC-NO (e.g., health certificates, need for quarantine).

12. Indicate animal identification method(s).

SpeciesCage card ☐ ☐ ☐Collar ☐ ☐ ☐Ear tag ☐ ☐ ☐Tattoo ☐ ☐ ☐Microchip; describe method of placement ☐ Method: ☐ Method: ☐ Method:

Other, specify

13. Indicate which vivarium/housing location will be used to house animals.

Building Check if room will be assigned by DOAC

Enter housing room # if NOT within DOAC assignment

Division of Animal Care (DOAC) in CSRB ☐

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Clinical Sciences Research Building (CSRB) ☐Lions/Neuroscience Center (LIONS) ☐Medical Education Building (MEB) ☐Dental School (DS) ☐Other, specify name and address

14. List the areas outside of DOAC facility where live animals will be taken (investigator lab or procedure room) and indicate how the animals will be used. Animals must be euthanized within 12 hours unless you obtain veterinarian prior approval to allow the animals to return to DOAC housing.

14a. List locations and activities.

Building (initials) Room # BSL

1,2,3 List the use of the live animal Identify euthanasia method (within 12 hrs)

If not euthanizing, check box to return animal to DAOC housing

☐☐☐☐

14b. Provide transportation and justification if returning animals to DOAC.Describe the method and containment to be utilized for transport, including the route and use of any elevators.Provide justification for the return of animals to DOAC.Provide veterinarian name and date of consult to approve the return.

15. Identify use of all drugs or research materials to be used in live animals. (Insert additional rows as needed.)Unless scientifically justified, pharmaceutical grade drugs must be used for live animal work. Use of controlled drugs MUST be recorded at the time used; drug logs will be inspected at least every 6 months. Guidelines on the use of drugs are available on LSUHSC-NO Animal Care website: https://intranet.lsuhsc.edu/animalcare/vet_services.aspx .

Species Drug/Agent Dose (mg/kg)

Route (SQ, IV, IP, IM, inhalation)

Administration(e.g., every 4 hrs. for 2 days post-surgery; once prior to euthanasia; twice weekly for duration of study)

Pharma grade?Yes

No

ANESTHETICS (local and general)☐ ☐☐ ☐☐ ☐☐ ☐☐ ☐

ANALGESICS or SEDATIVES☐ ☐☐ ☐☐ ☐☐ ☐☐ ☐

EXPERIMENTAL or THERAPEUTICS ☐ ☐

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Species Drug/Agent Dose (mg/kg)

Route (SQ, IV, IP, IM, inhalation)

Administration(e.g., every 4 hrs. for 2 days post-surgery; once prior to euthanasia; twice weekly for duration of study)

Pharma grade?Yes

No

☐ ☐☐ ☐☐ ☐

OTHER: Pathogens, Toxins, Chemicals, Radionuclides, rDNA, AAV ☐ ☐☐ ☐☐ ☐☐ ☐

16. Provide at least two methods of monitoring the appropriate depth of anesthesia during painful procedure(s) and/or surgery. ☐ Not Applicable ☐ Toe Pinch Reflex

☐Web Pinch Reflex

☐ Palpebral (Eye) Reflex

☐ Blood Pressure ☐ Tail Pinch Reflex ☐

Heart and Respiratory Rate

☐ Other, explain:

17. If any of the above listed drugs are not human or veterinary pharmaceutical-grade substances, provide a scientific justification for their use in live animals. Describe methods that will be used to ensure appropriate preparation (source, formulation, check for purity, storage, and sterility).

[Type here]

18. Identify the use of any human or animal biological materials or any other animal products that will be brought into this facility. Indicate if these have been or will be tested to certify them free of pathogens. Consult with veterinarian if uncertain what testing is required. (e.g., MAP - mouse antibody production; RAP - rat antibody production; PCR test)

Type Name of cell line, antiserum, etc. Source

Comes with health certificate

Indicate test method or enter ‘N/A’ if testing is waived by DOAC

Not applicable ☐Primary cell lines ☐Cell lines and their products, includes antibodies and ATCC cell lines

☐

Tissues and body fluids of rodent origin or had passage through rodents that had not been documented free of murine pathogens

☐

Cell lines grown on or exposed to Matrigel

☐

Other, specify:

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Environmental and biosafety issues should be addressed prior to submitting this application. Depending upon the IBC risk assessment, new SOPs may be required whereby you must consult with the Animal Care Facility veterinarians to modify or develop new SOPs specific to the procedures and/or the biosafety hazards of this study.

DOAC Biosafety [https:// intranet .lsuhsc.edu/animalcare/animal_biosafety_vids.aspx ]DOAC SOP [https:// intranet .lsuhsc.edu/animalcare/admin_services.aspx ]IBC Application [http://www.lsuhsc.edu/administration/academic/ors/ibc.aspx ] Radiochemical Use Application [http://www.lsuhsc.edu/admin/pfm/ehs/rad.aspx ]

19. Indicate the biosafety rating for housing and research activities conducted in DOAC. (Standard barrier (SPF) is the standard DOAC housing practice even if animal activity is only rated at BSL 1.)

DOAC housing biosafety level Research activities in DOAC procedure rooms or labs

Live animal research activities in PI lab

☐ ABSL1 or 2: standard barrier or SPF housing ☐ none☐

none

☐ ABSL2+ (includes modified barrier, use of toxins, carcinogens, lentivirus, etc.)

☐ BSL1☐

BSL1

☐ BSL2☐

BSL2

☐ ABSL3 (DOAC SOP 301) ☐ BSL3☐

BSL3

Describe the practices and procedures required for the safe handling and disposal of contaminated animals and material associated with this study. If applicable, describe methods for removal of radioactive waste and the monitoring of radioactivity.

Identify any potential hazards with the use of genetically modified animals to personnel, environment, or other animals.

Will there be a point in time when a change in the housing ABSL rating and safety precautions will be required?

☐ No change. ☐ Change or modification in ABSL rating will be required as indicated in the next item.

20. Indicate any housing or husbandry modification(s) to the standard DOAC husbandry that DOAC caretakers need to consider. Indicate when and how animals and/or cages will be identified (e.g., change in diet or fluids, cage size, monitoring, light cycles, safety, environmental, or enrichment not associated with single housing).

[Type here]

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21. Indicate if requesting an exception from social/pair housing of a social animal (includes rodents). Temporary single housing of an animal immediately after a procedure/experiment for recovery and then returning the animal to social/pair housing is not an exception and should be listed as a special husbandry event.☐ Not using a social animal. Describe

housing that is required. ☐ DOAC standard social/pair housing

will be used. (Only additional criteria may be added to enhance the SOP.)

☐ Check box to confirm that no modifications are required.☐ List additional criteria required to supplement the DOAC SOP.

☐ Initial single housing is required.

Describe and provide justification.

☐ Temporary change from initial social/pair to single housing. Explain why, when, and how housing will be modified.

☐ Permanent change from initial social/pair to single housing. Explain why, when, and how housing will be modified.

If single housing social animals, check which additional enrichment(s) will be provided.Enrichment Species Enrichment Species

☐ Autoclaved popsicle stick Mouse, rat ☐ Timothy hay cubes Rabbit☐ Better nest Mouse, rat ☐ Hanging toys Rabbit, pig, primate☐ Red houses Mouse ☐ Plastic chain Pig☐ Red tubes Rat ☐ Kong toy Primate☐ Kale Rabbit ☐ Fleece board Primate☐ Plastic ball Rabbit ☐ Paper bags Primate☐ Silver ball Rabbit, pig ☐ Puzzle feeder Primate☐ Other, specify:☐ No additional enrichment;

provide justification.

22. Use of non-human primates requires additional special programs. Indicate if using standard DOAC SOPs or if requesting a deviation or modification. For additional information, contact Animal Care veterinarians.☐ No non-human primates used in the study.☐ DOAC (SOP) for Primate Environmental Enhancement Program will be utilized.☐ Request exemption from the enhancement

program based upon the following justification. Identify specific parts or modifications if partial exemption is being requested.

Indicate how un-anesthetized primates will be handled outside of cage.☐ DOAC SOP for pole and collar technique will be utilized to move primates, including acclimation process.

All personnel utilizing the pole and collar technique are properly trained. (If also used to restrain the animal, complete section on using restraints.)

☐ Request SOP exemption or modification. Describe how primates will be moved, the acclimation process, the training of personnel. Provide justification for deviating from the SOP.

Indicate when and how often un-anesthetized primates will be moved.

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23. Will blood be collected from any live animals?

☐ No ☐ Yes, complete the table below.

Species Purpose of collection

Collection technique (e.g., tail lancing, tail vein, facial vein)

Frequency (e.g., every 2 weeks)

Volume per collection (ml)

Total number of collections

Provide scientific justification if the volume of blood is greater than the upper approvable limit of 1% of the animal’s body weight per collection per 24 hour period OR 1.5% of the animal’s body weight per 2 week period.

24. Will animals be subjected to food and/or fluid restriction(s) that will occur for a period longer than 24 hours?☐ No ☐ Yes, complete the table below.

Species Food Fluid Duration and frequency of restrictionTotal number of restrictions per animal during

lifetime

Time interval between

restrictions, if applicable

☐ ☐☐ ☐☐ ☐

24a. Provide justification for the restriction(s).

24b. Specify the threshold/criteria of well-being used for each variable for each species. Species Body weight (e.g., %

ad lib)Food/fluid consumed(e.g., vol. monitored daily)

Behavioral/clinical changes or abnormalities

Other criteria (e.g., urine/fecal output)

Describe steps taken to ensure adequate nutrition/hydration during the restriction period.

Body weights, food/fluid consumed, and behavioral/clinical changes or abnormalities must be recorded at least weekly; provide justification if this cannot be performed. Provide location where records can be accessed by the veterinarians if needed.

If animals develop physiological or behavioral abnormalities, indicate action(s) to be taken.☐ Animals will be permanently removed from restrictions and/or the study. ☐ Animals will be temporarily removed from restrictions.

Describe the criteria for returning an animal to the restrictions.

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25. Will any un-anesthetized animal be restrained for a period longer than 10 minutes?☐ No ☐ Yes, complete the below table

Species Method of restraint Type of device Duration and

frequency of restraint

Describe expected range of movement while restrained (normal, restricted posture, no movement, etc.)

Provide justification for the restraint.State alternatives that have been considered.Briefly describe physical restraint acclimation procedures. If animals will not be acclimated, provide justification. If animals fail to adapt, will they be removed from the study? If not, provide justification.

26. Will a paralytic be used on a live animal?☐ No ☐ Yes, complete the below table

Species Drug Dose Administration

Indicate how the animal will be anesthetized and what additional steps will be taken to monitor the appropriate depth of anesthesia and pain relief while using the paralytic.Provide justification for the paralytic.

27. Indicate the type of surgical procedures that will be performed on any ONE animal.☐ No surgical procedures will be performed.

☐ A minor procedure; defined as one that does not expose a body cavity and causes little or no physical impairment (wound suturing, peripheral vessel cannulation, percutaneous biopsy).

☐ A major operative procedure; defined as (a) any surgical intervention that penetrates and exposes a body cavity or (b) any procedure that produces permanent impairment of physical or physiological functions.

☐ A subsequent major operative procedure followed by recovery. List the procedures and justify below.

First major procedure Subsequent major procedure Justification

☐ A major operative procedure on an animal that has previously experienced a major operative procedure on another protocol. List the procedures and justify below.Major procedure on another protocol

Major procedure proposed on this protocol

Provide scientific justification for the use of these animals. Consult with the veterinarians prior to submitting this protocol to determine applicable APHIS requirement.

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28. In support of your certification to (1) reduce, (2) refine, and (3) replace the use of animals, please demonstrate that animal use is minimized, that the activities do not duplicate previous experiments, that alternatives to procedures falling under pain categories “D” and “E” were considered, that pain and distress are minimized, and that non-animal alternatives were considered. To address the above requirement, more than one set of key words and multiple searches may be necessary. Provide the following information of your web base searches. Retain a copy of your searches for future use or audit purposes. Search help is available on websites: Animal Welfare Info Center (AWIC): https://awic.nal.usda.gov/literature-searching-and-databases Guide to conducting alternative searches: http://altweb.jhsph.edu/resources/searchalt/index.html28a. Complete the table for searches conducted and explain the results in parts b through e.

Search engine(e.g., PubMed, CRISP, BIOSIS; Google is not acceptable)

Key word/criteria for search for duplication (required for all projects)

Key word/criteria for search for alternatives: (required for Category D or E experiments or procedures)

Inclusive years of search

(mm/yyyy to mm/yyyy)

Date search conducted

(mm/dd/yyyy)

28b.Explain how you determined the number of animals to be used in each group (e.g., statistical variability, specific experimental needs, power analysis). Additionally, provide justification if this duplicates any previous experiment.

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28c. (Refine) Indicate what alternative procedures or methods/techniques, including the use of drugs, were considered to minimize pain and/or distress (e.g., modified restraint, housing modifications, less invasive procedure, early humane endpoints).

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28d. (Replace) Identify non-animal alternatives that you have considered and explain why these alternatives are unacceptable. Explain why each species was selected. If you use ascites production to produce antibodies, you must also provide a specific reason for not using an in vitro system [e.g., mathematical models, computer simulation, in vitro biological systems, uniqueness of model (anatomic, physiologic, genetic, etc., comparable models or previous experience, comparability to human disease)].

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29. Which of the following may occur specifically as a result of your study manipulation?

Severe physiological or behavioral abnormality Less than severe physiological or behavioral abnormality☐ Death ☐ Weight loss less than 15% of body weight

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Severe physiological or behavioral abnormality Less than severe physiological or behavioral abnormality☐ Weight loss more than 15% of body weight ☐ Possible infection, including post-operative☐ Severe loss of ability to ambulate ☐ Infection or abscess ☐ Inability to eat or drink adequately leading to

severe dehydration or malnutrition☐ Mild dehydration

☐ Severe neurological signs (seizure, paralysis, head tilt, circling)

☐ General weakness

☐ Severe progressive dermatitis ☐ Diarrhea☐ Rough hair coat, hunched posture, lethargy, or

persistent recumbences☐ Mild seizures/head tilt

☐ Markedly reduced response to stimuli ☐ Mild difficulty breathing ☐ Labored breathing/cyanosis ☐ Mild skin abnormalities ☐ Tumor associated disease (check all that apply): ☐ Mild ataxia☐ Tumor growth exceeding 10% of original body mass ☐ Excessive urination☐ Tumor necrosis or ulceration ☐ Mild behavioral changes☐ Tumor infection ☐ Tumor growth less than 10% of original body mass☐ Tumor growth that impairs ambulation Other less than severe adverse effect:

Other severe adverse effect: ☐☐ ☐☐ ☐Explain any other adverse events that are specifically age related:

30. Describe your plan of action for adverse effects. Prior to submitting this application, consult with the veterinarians to formulate appropriate treatment and management plans and the ultimate disposition of an animal. The veterinarians are authorized to make the final diagnostic, treatment, or euthanasia decisions.30a. Indicate how often animals will be monitored.

Select all signs of pain or distress that will be monitored.☐ Redness or swelling around surgical site ☐ Muscle rigidity, lack of muscle tone ☐ Decreased food and water consumption ☐ Dehydration/skin tenting/sunken eyes ☐ Weight loss; body condition ☐ Twitching, trembling, tremor ☐ Self-imposed isolation/hiding ☐ Vocalization ☐ Self-mutilation, gnawing at limbs ☐ Grinding teeth ☐ Rapid breathing ☐ Biting/growling/aggression ☐ Open-mouth breathing/nasal discharge ☐ Tearing (may include porphyria red tears) ☐ Abdominal breathing ☐ Lack of blinking reflex, ocular discharge ☐ Increased/decreased movement ☐ Restless sleep ☐ Unkempt appearance (erect, matted, or dull hair coat) ☐ Dilated pupils ☐ Abnormal posture/positioning (e.g., head- pressing,

hunched back)☐ Increased salivation

☐ Other, specify:☐ ☐☐ ☐30b. Describe the exact threshold at which the animal will be removed from the study or euthanized.

30c. If keeping the animal in the study during signs of pain or distress or if death is used as an endpoint, provide scientific justification to evaluate the risk for negative impacts on animal well-being versus benefit of successful completion of project. Death as an endpoint is defined as allowing death to occur as a result of the experimental manipulation instead of euthanizing the animals when it may be deemed necessary to do so. Since death as an endpoint is rarely used, strong justification is required. A consult with the veterinarians is required when morbidity is not an alternative. Date:

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31. Indicate method(s) of euthanasia. If multiple methods will be used with the same species, indicate which method will be used and when. All methods and/or apparatus being used must be consistent with current recommendations of the Panel on Euthanasia of the American Veterinary Medical Association.☐ Compressed CO2 (Anesthesia is NOT required, DOAC SOP 323. Method is NOT acceptable for rodents <7 days old.)

Species

☐ Anesthetic overdose

Species Drug Dose Route

☐ Exsanguination under anesthesia

Species

☐ Decapitation while under anesthesia ☐ Cervical dislocation while under anesthesia (not acceptable for rodents <7 days old)

Species

☐ Decapitation without anesthesia ☐ Cervical dislocation without anesthesia (not acceptable for rodents <7 days old)

Species

Provide scientific justification for not using anesthesia prior to decapitation or cervical dislocation.

If performing decapitation or cervical dislocation without the prior use of anesthesia, identify the personnel and provide information on their training and experience utilizing the technique.

For decapitation without anesthesia, identify the equipment and the maintenance procedures for the equipment (e.g., frequency blade is checked and how the blade is sharpened or if contracted services are used), or indicate if utilizing DOAC SOP.

32. Indicate method to confirm death. If multiple methods will be used with the same species, indicate which method will be used and when.

☐ Decapitation

Species

☐ Thoracotomy

Species

☐ Other, explain

Species

Are all methods and/or apparatus being used consistent with current recommendations of the Panel on Euthanasia of the American Veterinary Medical Association?

☐ Yes ☐ No. Provide scientific justification why the proposed method must be used.

Will all animals in this protocol be euthanized?

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☐ Yes ☐ No. Indicate disposition of animals not euthanized at the completion of the project.

33. If this project will be conducted in an institution other than LSUHSC-NO, provide the following information. Such projects must be approved by the IACUC at each institution. Consult with the Office of Research Services Grants and Contracts office for any additional institutional requirements.

Name of other institution

Name of the facility and location (street, city, state) where the animal work will be conductedAAALAC membership status and date

PHS OLAW assurance status

Date of current IACUC approval

Submit a copy of the approved IACUC protocol and the IACUC approval. LSUHSC IACUC will not review this application without these documents.

34. Indicate which required supporting documents are being submitted with this application.

Type of document Document file name☐ Grant vertebrate animal section☐ Another institution’s IACUC

application☐ Another institution’s IACUC

approval or assurance letter☐ Addendum 1 –Surgical Procedure☐ Addendum 1 –Surgical Procedure☐ SOP☐ SOP

Other supporting documents:☐☐

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Institutional Animal Care and Use Committee

Principal Investigator’s Protocol Assurance Statement

Title of project [must match front page]:

Principal investigator name:

I acknowledge responsibility for the work described here. I certify that I and all the individuals participating in this project are listed in the COI Team Member Form and have a

currently active annual conflict of interest (COI) disclosure. “Currently active” means the COI disclosure has been updated to reflect any COI acquired as a consequence of this specific research project.

I assure that the individuals listed in this application are qualified to conduct the study in a humane and scientific manner consistent with PHS document “Guide for the Care and Use of Laboratory Animals” and the provisions of the Animal Welfare Act and are knowledgeable of the procedures for reporting animal welfare concerns.

I certify that the individuals listed in this application are authorized to conduct the listed procedures involving animals under this proposal, have attended the institutionally required investigator training course, and received training in: the biology, handling, and care of this species; aseptic surgical methods and techniques (if necessary); the concept, availability, and use of research or testing methods that limit the use of animals or minimize distress; the proper use of anesthetics, analgesics, and tranquilizers (if necessary).

I certify that all individuals working on this proposal who are at risk were informed of the institution's occupational health and safety program.

I certify that I gave full consideration to reduce, refine, and replace the use of live animals and that these experiments do not unnecessarily duplicate previous work using animals.

I certify that I have reviewed the pertinent scientific literature and the sources and/or databases and have found no valid alternative to any procedures described herein that may cause more than momentary pain or distress, whether it is relieved or not.

I certify that I will obtain approval from the IACUC before initiating any minor or significant changes in this study. I certify that I will notify the IACUC regarding any unexpected study results that impact the animals; and that any

unanticipated pain or distress, morbidity, or mortality will be reported to the attending veterinarian and the IACUC. I certify that I am familiar with and will comply with all pertinent institutional, state, and federal rules and policies.

By signing, the principal investigator certifies each of the above statements.

______________________________________________________________________Principal Investigator Date

Print only this assurance page, sign and submit this signature page to the IACUC Office at RCB206 or send as a PDF document by email. Email the entire application to IACUCoffice@lsuhsc.edu in the original WORD format.

****** LSUHSC-NO IACUC USE ONLY *** DO NOT SUBMIT TO GRANTING AGENCY ******

This IACUC # __________was approved by the LSUHSC-NO IACUC. In the judgment of the IACUC, the procedures delineated in this application conform to the pertinent federal rules and regulations regarding use and care of animals. Annual re-approval will be required and routine inspections should be expected. You must submit an amendment prior to implementing any changes.

Approval Signature: ________________________________ Date of Approval: _____________Jennifer Pepping, DVM, IACUC Chair

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Rev. 2/26/18

Conflict of Interest Team Member Form

Each person involved in research must complete an annual COI form in the COI Risk Manager system. If a team member's participation in this project creates a new COI, their COI form must be updated in the COI Risk Manager system.

The IACUC will forward this form to the COI Office to verify each member’s COI is current.

Principal investigator name:

Title of project:

IACUC#

NameInstitution Name E-mail Address

First Last