Jawatankuasa Penjagaan dan Penggunaan Haiwan Institusi USM (JKPPH USM) USM Institutional Animal Care and Use Committee (USM IACUC)

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1 Jawatankuasa Penjagaan dan Penggunaan Haiwan Institusi USM (JKPPH USM) USM Institutional Animal Care and Use Committee (USM IACUC) CHECKLIST OF ANIMAL ETHICS APPLICATION, PLEASE TICK ( ) IN THE BOX BELOW Penyelidik Utama: Principle Researcher/Teacher No. DOCUMENTS 1 Borang Permohonan Kelulusan Etika (Haiwan) Animal Ethics Approval Application Form 2 Cadangan Penyelidikan Research Proposal 3 Tandatangan Penyelidik Utama/Pengajar Principle Researcher/Teacher signature 4 Tandatangan Penyelidik Bersama Co-researchers signature 5 Carta Alir Flow chart 6 Tarikh Memulakan Penyelidikan Date of the project starting 7 Dokumen-dokumen tambahan yang berkaitan (jika ada) Additional related documents (if any) APPLICANT PLEASE TICK ( ) USM IACUC PLEASE TICK ( ) Tarikh: (Tandatangan Penyelidik) (Tandatangan Penerima) (Date) (Researcher signature) (Recipient signature)

2 Office Use Only Proposal Received Date IACUC File No. Received by USM Institutional Animal Care and Use Committee APPLICATION FOR APPROVAL OF A PROJECT INVOLVING THE USE OF ANIMALS NOTE: 1. Please complete the application form in accordance with the Guidelines for the Care and Use of Animals for Scientific Purposes (available at Incomplete application will result in the return of the application and delay in the granting of the approval. 2. Attach all relevant documents based on the checklist. 3. Please refer to Appendix A for guideline in fulfilling the form. 4. Application must be word-processed and forwarded to the Chairperson, Institutional Animal Care and Use Committee (IACUC), Health Campus, Universiti Sains Malaysia (USM), Kubang Kerian, Kelantan. 5. Please submit the SOFTCOPY of application and the checklist from the following jkpph@usm.my 6. Please submit the signed HARDCOPY to the Secretary, Institutional Animal Care and Use Committee (IACUC), Division of Research & Innovation, Health Campus, Universiti Sains Malaysia, Kubang Kerian, Kelantan. Tel: , Fax: NAME OF PRINCIPAL ANIMAL RESEARCHER/TEACHER SCHOOL / CENTRE PROJECT TITLE FOR ANIMAL STUDY TITLE OF THE GRANT/PHD/MASTER PROJECT (if different from above)

3 SECTION 1: ADMINISTRATION 1.1 TYPE OF APPLICATION (Please tick [ ] one or more) (a) Research i Fundamental research ii iii iv v Applied research Applied animal model mimicking human disease Applied animal model mimicking the veterinary disease Toxicology study (b) Teaching (c) Others (Please specify) (e.g. Breeding, standard operating procedure) 1.2 LIST ALL PERSON INVOLVED IN THE PROJECT (including principal researcher)* No. Name School / Department Role/ Contribution I/C / Passport No. Contact [ & H/P] Signature & Date (a) (b) (c) (d) (e) *Please ensure that this section is signed by the persons listed *Students involved in the project should be listed

4 1.3 DURATION OF ANIMAL STUDY Please note that ethical clearance can only be given for a maximum period of 3 years (research) and 3 years (teaching) starting from the approval date Proposed commencement: Date: Month: Year: Expected completion: Date: Month: Year: 1.4 ANIMAL(S) REQUESTED No. Scientific / Common Name Strain Name (Indicate With an (*) If Genetically Modified) No. of male (Age / Weight) No. of female (Age / Weight) Total (No.) Dropout (%) Grand Total Source of animals Please state the supplier of the animals use for the experiments Location of animals Please indicate all the locations at which research using animals will be conducted and housed

5 1.4.4 PERMITS REQUIRED: (Please tick [ ]) (YES / NO ) if YES please provide details of appropriate permits held (a) Holder: (b) Issuing Agency: (c) Date of Issue: (d) Serial No.: (e) Period of Validity: 1.5 HEALTH AND / OR SAFETY RISK (a) Does the project involve procedures or agents that might pose a health risk to other animal and / or personnel? (Please tick [ ]) (i) Ionizing Radiation : YES NO ii) Carcinogen / Teratogen: YES If Yes, please state the agent: If Yes, please state the agent : (iii) Pathogenic Organism : (iv) Others : YES NO YES If Yes, please state the agent : If Yes, please state the agent : NO NO (b) If YES to any of the above, please explain the risk and describe the precaution that will be taken. (c) Describe the facilities available.

6 1.5.2 CLASSIFICATION OF PROJECT Please tick [ ] one or more to indicate the category that best describes all procedures to be carried out on the animals in the project A B C D E F G H I J K L A project requiring animals to be sacrificed for the isolation of embryo and tissue/organ specimen. The procedure to be carried out under anaesthesia and the animals to be sacrificed without regaining consciousness. Survival after an intervention, which causes major or prolonged stress (e.g. major surgery and prolonged restraint). Survival after an intervention, which causes minimal stress of short duration (e.g. venepuncture, brief restraint and skin irritation). Animal behavior experiments, including pain assessment. Infective or biohazard experiments. Genetic modification of animals. Toxicity studies. Purely breeding projects. Production of antisera. Blood vessel cannulation. Other procedures Please specify. SECTION 2: JUSTIFICATIONS FOR THE USE OF ANIMALS IACUC must be satisfied that the use of animals is justified, based on whether the scientific or educational value of the work outweighs the potential impact on the animal being used 2.1 PROJECT SUMMARY (a) State the objective of the project (b) Provide a brief background of the study (not more than 250 words).

7 (c) Provide flowchart of the study and indicate the number of animals to be used in the flowchart (Attached as an appendix) (d) Justify the number of animals requested based on statistical calculations, guidelines, published study or other methods (e) Justify the choice of species / strain of the animals to be used (provide references)

8 (f) State the housing and husbandry for special requirements (if applicable) Caging or housing Maximum per cage Special care Diet Environmental enrichment 2.2 ETHICAL IMPLICATION OF THE PROJECT Identify all factors/procedures that may have an impact on an animal s well being i.e any activities not part of the ordinary husbandry 2.3 REPEATED USE OF ANIMALS, Please tick [ ] Have any of the animals been the subject of a previous research or teaching activity? NO YES, (if YES, please explain why it is necessary to reuse the animals)

9 SECTION 3: PROJECT DETAIL Procedures to be carried out on the animals 3.1 ANAESTHESIA Will anaesthesia be used in the experiment (except for euthanasia) (Please tick [ ]) Yes No (if YES, please complete the table below) (a) Please complete the table below for each anaesthetic agent or mixture used (please duplicate the table for different groups/species/ Agent name Route of Administration Dose/volume Duration (explain in instruction) (b) Describe how will you monitor recovery from anaesthesia: (c) Clinical signs to ensure anaesthesia is adequate: 3.2 NEUROMUSCULAR BLOCKING AGENT Will Neuromuscular Blocking agent be used in the experiment, (Please tick [ ]) Yes No (if YES, please complete the table below) Agent Dose/volume Route of administration Justification for use of neuromuscular blocking agent 3.3 SURGERY

10 (a) Will surgery be performed during the experiment, (Please tick [ ])) Yes No (if YES, please complete the table below) Describe in detail, the surgical procedures to be carried out on the animals Name the person identified to perform the procedure Is the person familiar with the procedure (Please tick [ ]) Trained Yes No 3.4 OTHER INTERVENTIONS (a) Please justify the intervention to be performed in the experiment (Please tick [ ])) Outline the procedure: State the person identified to perform the procedure: 3.5 GENETIC MODIFICATION OF ANIMALS

11 (a) Does the project involve the use or creation of genetically modified (GM) animals e.g.: transgenic, knockout, or mutant animals (Please tick [ ]). Yes No (if YES, please complete the table and section below). Animal Species & Strain (Common name) Name and function of genetic modified Phenotype of animals (b) If application for the creation of animals, please state the method/used that will be used. (c) Provide details of the breeding and maintenance of the GM line. Please include personnel and facility involved. SECTION 4: HUSBANDRY & MONITORING

12 (a) Who will carry out the daily husbandry and monitoring of animal, including weekends and holiday? Provide name and contact number. (b) Monitoring during and after procedures/interventions; List specific signs to be monitored and their frequency. Please provide the monitoring checklist you will use to record these observations. SECTION 5: FATE OF THE ANIMALS (a) What is the maximum period of time that an individual animal or a group of animals will be used in this project? (b) If animals are to be sacrificed, please fill the table below: Method Agents Route of administration The dosage used The person performing the procedure (c) What will be the method of disposal of euthanized animals? (d) If animals are not sacrificed, state what happen to them? SECTION 6: DECRALATION BY PRINCIPAL RESEACHER/TEACHER

13 I hereby declare that I and co-researcher have the appropriate qualification and experience to perform the procedures described in this project. I am familiar with the provisions of the USM rules and regulation in animals for the care and use of Animals for Scientific Purposes; and accept responsibility for the conduct of the experimental procedures detailed above; in accordance with the requirement of the rules and regulation laid down by the USM Institutional Animal Care and Use Committee. I further declare that the procedures described in this project do not constitute unnecessary repetition of work previously carried out by other research workers or myself, and that each person engaged in this project has been adequately instructed in, and is competent to perform, procedures that they are carried out. If they are not already skilled in the procedures, I will be responsible for seeing that they obtain the necessary training in advance, so that each procedure on an animal will be carried out in the most appropriate manner. Signature of Principal researcher/teacher : Date : Official stamps: SECTION 7: CERTIFICATION FROM IACUC (CHAIRPERSON / AUTHORISED REPRESENTATIVE) Name : Position : Signature : Date :