UNIVERSITY OF WISCONSIN-RIVER FALLS
ANIMAL USE PROTOCOL

Date ____________                   Protocol number (provided by Grants Office) _____________

1. Name                                                                     Office                                                        

Phone                                                          (office)                                                           (home)

2. Title of Activity                                                                                                                        

3. Beginning Date of Activity:_____________ Ending Date of Activity:______________

Note: Protocols can be approved for a short time, a semester, an academic year, or for a maximum of 12 months. The requested duration should include a time period long enough to encompass all activities involving animal subjects, but no longer.

4. Type of Activity (check where appropriate)

_____ Teaching           ______ Demonstration          _____ Research           _____ Husbandry

If the activity is in connection with a UWRF course what is the course no. and name?

__________________________________________________________

5.  As the Principal Investigator, you have the responsibility to insure the humane care of the animals used in your protocol.  How will the personnel handling the animals demonstrate that they understand the principles of safe and humane care and handling?  Hor instance, will you provide training?  Will you test the personnel?

Do you certify that all personnel handling the animals will be trained in the responsible use and care for that species? ______ Yes ______ No

6. Unless another veterinarian is listed, it will be assumed that the veterinarian to be notified for veterinarian care is:
             Dr. Brenda Bray
             Animal Care Center
             Hudson, WI 54016
             phone: 386-8878

             _______________________________ Veterinarian
             _______________________________ Address
             _______________________________
             _______________________________ Phone

 7. Which species is to be used and the approximate numbers?

_____ Mice          _____ Frogs          _____ Cattle          _____ Horses          _____ Rats
_____ Turtles       _____ Sheep          _____ Fish             _____ Rabbits         _____ Cats
_____ Swine        _____ Hamsters     _____ Dogs           _____ Goats            _____ Other (specify)
                                                                                                                                               

8. Where are animals housed? _________________________________________________

9. Where are the surgical and non-surgical manipulations or procedures to be performed?          
                                                                                                                                               

10. Please attach a copy of your research procedure or management/care/ handling procedure which deviates from normal. (Could come from your grant proposal or class handout.) 

Please remember that the purpose of this protocol review is to assure the humane care and treatment of animals. Your attached procedure should describe the surgical and non-surgical manipulations or practices that are employed. All drugs, anesthetic methods, postsurgical monitoring and care procedures, euthanasia techniques, and methods of tissue disposal should be cited.

11. Which euthanasia technique will be employed and how will tissue be disposed if not anticipated in procedure submitted in #9?

12. What is the final dispensation of animals and animal tissues?

13.  Does the activity proposed under this protocol duplicate previous experiments or demonstrations?  If so, why is it necessary?

14.  Please justify your choice of species for this project and the number of animals you will use.

                                                                                                                                               
                                             Proposed and/or Principal Investigator

                                                                                                                                               
                                 Chair Signature*                                                  Department

                                                                                                                                               
             Animal Care Committee Signature                                 Approved or Disapproved

Revised and approved by IACUC, 3/17/97, 10/7/98,11/9/05

* Signature required as a form of notification

PLEASE SUBMIT COMPLETED ANIMAL USE PROTOCOL REVIEW FORM TO THE UNIVERSTIY OF WISCONSIN-RIVER FALLS GRANTS OFFICE, 104 NORTH HALL.

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Page Author:  Bill Campbell

Last Updated:  3/01