PROTOCOL FORM USE OF LIVING, VERTEBRATE ANIMALS Institutional Animal Care and Use Committee Texas Woman’s University Submit one electronic version to the IACUC secretary in the Office of Research and Sponsored Programs (ORSP) at least 10 working days prior to the date of the next IACUC meeting. PROJECT TITLE: INVESTIGATORS: (List all investigators involved with the protocol and signify Principal Investigator with an asterisk*) DEPT. (Principal Investigator): DEPT. PHONE: EMAIL ADDRESS (Principal Investigator): PROPOSED DURATION OF PROJECT: (MM/DD/YY) to From FUNDING OR PROPOSED FUNDING SOURCE: PROTOCOL NUMBER: (if application is other than a new proposal or pilot project) PROJECT CLASSIFICATION: (Check any that apply.) A. Grant Proposal (External Source) B. Grant Proposal (Internal Source) Identify Source Identify Source New Proposal or Pilot Project Modification of Ongoing Project Triennial Review of Funded Project Project Supplement C. Thesis/Dissertation Project D. Course E. Breeding Colony F. Other (Explain) PEER REVIEWER PEER REVIEWER (Signature) (Print) (Attach letter or email if reviewer is at another institution) IACUC REVIEW (for committee use only) Protocol Number: ____________ Date Protocol Application was Received by IACUC: (MM/DD/YY) _____ Approved _____ Modifications required for approval _____ Disapproved Other Comments: Additional Review Required: _____No _____Yes (If yes, check all that apply.) _____Radiation Safety Committee _____Institutional Biosafety Committee IACUC Approval _____________________________ Date____________________ (IACUC Chair’s Signature)
PROTOCOL FORM USE OF LIVING, VERTEBRATE ANIMALS Institutional Animal Care and Use Committee Texas Woman’s University Submit one electronic version to the IACUC secretary in the Office of Research and Sponsored Programs (ORSP) at least 10 working days prior to the date of the next IACUC meeting. PROJECT TITLE: INVESTIGATORS: (List all investigators involved with the protocol and signify Principal Investigator with an asterisk*) DEPT. (Principal Investigator): DEPT. PHONE: EMAIL ADDRESS (Principal Investigator): PROPOSED DURATION OF PROJECT: (MM/DD/YY) From to FUNDING OR PROPOSED FUNDING SOURCE: PROTOCOL NUMBER: (if application is other than a new proposal or pilot project) PROJECT CLASSIFICATION: (Check any that apply.) A. Grant Proposal (External Source) B. Grant Proposal (Internal Source) Identify Source Identify Source New Proposal or Pilot Project Modification of Ongoing Project Triennial Review of Funded Project Project Supplement C. Thesis/Dissertation Project D. Course E. Breeding Colony F. Other (Explain) PEER REVIEWER PEER REVIEWER (Signature) (Print) (Attach letter or email if reviewer is at another institution) IACUC REVIEW (for committee use only) Protocol Number: ____________ Date Protocol Application was Received by IACUC: (MM/DD/YY) _____ Approved _____ Modifications required for approval _____ Disapproved Other Comments: Additional Review Required: _____No _____Yes (If yes, check all that apply.) _____Radiation Safety Committee _____Institutional Biosafety Committee IACUC Approval _____________________________ Date____________________ (IACUC Chair’s Signature)
iacuc-protocol-form.docx