2018 COVER PAGE - Checklist for Significant Change Application PI Name: Protocol Number: Protocol Title: Check (“x”) the categories that are relevant to this application: For projects supported by a federal granting agency: I have attached an appendix file that includes the cover page, abstract, and vertebrate animal section with this application. I avow that this significant change does not constitute a in scope” to the “change funded research project that must be reported to the funding agency. I have attached a copy of the new signed If changed from the original submission, Institutional Research Safety Report Form from EHS to this application. The significant change involves the use of hazardous chemicals, biological hazards, or recombinant DNA in live animals and I that was not listed in the original approved protocol have approved relevant SOPs, or have submitted new SOPs for new hazardous materials: New personnel listed on this protocol application have completed enrollment in the occupational health and safety program, including a medical evaluation. The new individuals are: The significant change includes the use of a controlled substance/s in the live animal that was in the original protocol approved by IACUC. This includes: not listed The significant change involves the use of radioactive materials or irradiation with live animals in the original protocol approved by IACUC and I have attached a that was not listed copy of the approval from radiation safety officer to this application. The significant change includes the use of a laser in the live animal in the that was not listed original protocol and I have submitted a copy of the approved laser registration form. I have checked the attestation box on the last page of the application and typed my name as an electronic signature. APPLICATION FOR SIGNIFICANT CHANGE TO ANIMAL PROTOCOL I. ADMINISTRATIVE INFORMATION: Principal Investigator (PI): Name: Degree/Title: Dept. / Institute:
2018 COVER PAGE - Checklist for Significant Change Application PI Name: Protocol Number: Protocol Title: Check (“x”) the categories that are relevant to this application: For projects supported by a federal granting agency: I have attached an appendix file that includes the cover page, abstract, and vertebrate animal section with this application. I avow that this significant change does not constitute a “change in scope” to the funded research project that must be reported to the funding agency. If changed from the original submission, I have attached a copy of the new signed Institutional Research Safety Report Form from EHS to this application. The significant change involves the use of hazardous chemicals, biological hazards, or recombinant DNA in live animals that was not listed in the original approved protocol and I have approved relevant SOPs, or have submitted new SOPs for new hazardous materials: New personnel listed on this protocol application have completed enrollment in the occupational health and safety program, including a medical evaluation. The new individuals are: The significant change includes the use of a controlled substance/s in the live animal that was not listed in the original protocol approved by IACUC. This includes: The significant change involves the use of radioactive materials or irradiation with live animals that was not listed in the original protocol approved by IACUC and I have attached a copy of the approval from radiation safety officer to this application. The significant change includes the use of a laser in the live animal that was not listed in the original protocol and I have submitted a copy of the approved laser registration form. I have checked the attestation box on the last page of the application and typed my name as an electronic signature. APPLICATION FOR SIGNIFICANT CHANGE TO ANIMAL PROTOCOL I. ADMINISTRATIVE INFORMATION: Principal Investigator (PI): Name: Degree/Title: Dept. / Institute: