ࡱ > \ ^ [ \ bjbj 4T \ ! # h - - - - - f# h# h# h# h# h# h# $ O% ' b # # - - # - - f# f# - 0Bг R# # 0 # S( 4 v S( S( # # # S( : Roger Williams University
Institutional Animal Care and Use Committee (IACUC)
Application to use ANIMAL PRODUCTS from Vertebrate Animals for Research and/or Teaching
Contact InformationName:Department:Telephone #:Email:Animal Product Use TypePlease circleFaculty ResearchStudent ResearchClass ActivityIs this a product that could become a covered animal?YesNoPlease check appropriate items:TissuesBloodUrineCarcassesEmbryosOther (Specify)Animal Species from which product is obtained:Source of Material91Other Institution (specify)
SlaughterhouseOther (specify)Are Permits Required?Yes
If yes, attach copies of applicable state or federal permitsNoPermit AgencyPermit NumberExpiration Date:Method of disposal:Check all that apply:I assure that all slaughterhouse materials used are obtained from a USDA inspected facilityI assure that all vendors used are licensed vendorsI assure that no additional animals are euthanized under this protocol nor are any additional procedures carried out on these animals prior to their death, for the purpose of the applicants researchI am aware that an additional protocol may be required if this product can result in the formation of a covered animalSignature of Principal Investigator:Date:For Materials Acquired From Investigator at 91:Under what IACUC protocols are the products obtained:Signature of PI from whose protocol animal products are obtained:
Date:For Materials Acquired From Animals at Other Institution(s):Attach a copy of the appropriate approval document from that Institutions IACUCFor Materials Acquired From Animals via a Licensed Vendor(s):List the Vendor and contact information and Purchase Order #:Vendor PHS Assurance Number (if available):
FOR IACUC RECORDS ONLYAPPROVALDATE:DENIEDDATE:NEED FOR PROVOST APPROVALYESNO
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