Institutional Animal Care and Use Committee (IACUC)


Tissue Collection and Use Protocol in Rodents Application Form

Instructions: If applicable, submit this Form with the IACUC Animal Use Protocol (AUP)
1. Administrative Information
Project Title:
Project Type:
Principal Investigator (PI):
Academic Rank:
Faculty:
Department:
UOB Extension:
Cell phone:
Email:
2. Animals to be Used:
Species (Common Name)
Strain
Gender
Age
Body Weight
Building & Room Number where tissue collection and use will be performed
Animal Housing Location - University Facility: If no, specify location
3. What type of tissue will be collected?
4. How the tissue samples will be collected?
5. How the tissue samples will be fixed or prepared for use?
6. How the tissue samples will be used?
7. What is the number of tissue samples that will be collected from each animal?
8. What is the proposed number of animals to be used for tissue collection?
9. Will any manipulations of live animals (such as special diet, dietary changes, food or water restriction, or hormonal treatment) be performed prior to tissue collection?

If yes, provide specific information on the methodology and animal care considerations.
10. Will the tissue samples be transported outside the University facilities?

If yes, indicate the means of transport and justify the place of use
11. Will the animals be restrained prior to the tissue collection procedure?

If yes:
a. Indicate the duration of the restraint.
b. Describe how the animals will be restrained.
12. Will the animals be anesthetized prior to the tissue collection procedure?

If yes:
Anesthetic
Dose (mg/Kg)
Volume (ml)
Administration route
If no, justify the decision of not administering anesthetic agents.
13. Will the animals be euthanized immediately following tissue collection?

If yes, indicate:
Euthanizing agent
Dose (mg/Kg)
Volume (ml)
Administration route
If no, justify the decision of not administering euthanizing agents.
14. List all personnel contacting the animal tissues
15. Experience and Training of the investigator(s)
a. The PI has the technical expertise needed to perform tissue collection and use:
b. All personnel listed on the AUP have had the appropriate training and experience to perform tissue collection and use:
Principal Investigator
Signature
Date