ࡱ> FHEW bjbj KFxeaxea"zz   8BtD "}$Z!X^}}PQUi0!.!!X!zB :  Date: ________________ Check whether your proposal is: Original: _________ Revised: _________ Renewal: _________ (Date previously approved: _________ ) Principal Investigator/Instructor: ____________________________________ Department: ____________________ Funding Agency: _____________________ Project Title/Course Name and Number: __________________________________ ___________________________________________________________________ ___________________________________________________________________ 1. Animal Species: _______________________ Number: _______ Sex: ________ 2. Maximum number of animals in animal facility at one time: __________ 3. Number of days each animal will be housed (approx.): _______________ 4. Duration of study (start and finish dates): _______________________ 5. Live animal methodology (use additional sheet if necessary):_______ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ 6. Justification (rationale) for use of proposed animal model (use additional sheet if necessary): ____________________________________ ___________________________________________________________________ ___________________________________________________________________ 7. Abstract of grant proposal/introduction to lab (attach to this form). 8. Number of procedures per animal: _____________ 9. Check the statement(s) that apply to your procedure: _____ General anesthesia without recovery _____ Recovery from general anesthesia _____ No pain _____ Normal postoperative discomfort (no drugs) _____ Pain and drugs _____ Pain and no drugs (justify in writing) 10. If the proposed research will produce more than momentary or slight pain or distress to animals, have alternative procedures not requiring the use of animals been considered? _____ Yes _____ No _____ N/A Provide documentation of the methods you used to determine that alternative procedures are not available or are unacceptable (e.g., literature review, Animal Welfare Information Center, Medline search). 11 List the anesthetics, tranquilizers or analgesics to be used during the procedure. State drug, dosage, route of administration and frequency given: ___________________________________________________ ___________________________________________________________________ ___________________________________________________________________ 12. Method of euthanasia at termination of the experiment. Give drug, dose, and route of administration: _________________________________ ___________________________________________________________________ ___________________________________________________________________ 13. Will radioisotopes be used in live animals? _____ No _____ Yes Type: __________________________________________________________ Approval of Radiation Safety Officer: ______________________________ Date :_____________ 14. Does this project involve any potentially hazardous biological, chemical, or physical agents? __________ If yes, explain: ___________________________________________________ ___________________________________________________________________ I hereby certify that I am familiar with the PHS policy on the humane care and use of laboratory animals and will conform to all laws, regulations, and recommendations as promulgated by the National Institutes of Health, USDA, and all applicable federal, state, local governmental agencies, or LFC policies. I also assure that this activity does not unnecessarily duplicate previous experiments. ______________________________________________ ____________ Investigator Date Date of Review: ____________________ Committee Action: Approved ________ Suggested Revisions: _____________________________________________ ___________________________________________________________________ ___________________________________________________________________ Disapproved: ____________________ Signatures of approval:_______________________________ _____________ IACUC Committee Chair Date ___________________________ ________________ Veterinarian Member Date Form Revised 12/1/01     PAGE  PAGE 2 LAKE FOREST COLLEGE INSTITUTIONAL ANIMAL CARE & USE COMMITTEE ANIMAL UTILIZATION REVIEW FORM 89BCMNab   . 0 1 2 W 񥘈yj[Nh#>*CJOJQJaJh\Vh+GCJOJQJaJh\VhzCJOJQJaJh\Vh1CJOJQJaJh\VhG B>*CJOJQJaJhQG>*CJOJQJaJh\Vhe?!>*CJOJQJaJh\VhI0RCJOJQJaJh\Vh* CJOJQJaJh\VhCJOJQJaJh\Vhd*ZCJOJQJaJh\VhG BCJOJQJaJ8Ma2 ~ sss' & p@ P !hdhx1$^h`gd0|$ & p@ P !h<1$^h`gd" & p@ P !h1$^h`gd$ # p@ P !1$a$gdd*ZW X z | } ~    ! 8 9 B C O P X ŵŵŵxhYJh\Vh*CJOJQJaJh\VhbCJOJQJaJh\Vh>>*CJOJQJaJh\Vh4CJOJQJaJh\VhYCJOJQJaJh\Vhj>*CJOJQJaJh\VhaCJOJQJaJh\VhG B>*CJOJQJaJh &>*CJOJQJaJh\Vhp>*CJOJQJaJh\VhG BCJOJQJaJh\VhomCJOJQJaJ~  Z :  ] c' & p@ P !Bdhx1$^`Bgd9"% & p@ P !>dh1$^`>gd9"' & p@ P !>dhx1$^`>gd9"% & p@ P !hdh1$^h`gd9" X Y Z ] 6 8 9 : = vfVFh\Vh>*CJOJQJaJh\Vh9J+>*CJOJQJaJh\Vhb>*CJOJQJaJh\Vh ECJOJQJaJh>>*CJOJQJaJh\Vh>*CJOJQJaJh\Vh>>*CJOJQJaJh\VhbCJOJQJaJh\VhG BCJOJQJaJh\VhYCJOJQJaJh\VhG B>*CJOJQJaJh\Vh0#Z>*CJOJQJaJ       Y Z [ \ ] ^ ` 樂樂樂vgWh\Vhe>*CJOJQJaJh\Vh1CJOJQJaJh\VhCJOJQJaJh\Vh:UCJOJQJaJh}hG B>*CJOJQJaJh}>*CJOJQJaJh\Vh>*CJOJQJaJh\VhG BCJOJQJaJh\Vh~HCJOJQJaJh\VhG B>*CJOJQJaJh\VhJ>*CJOJQJaJ 1 3 4 5 6 y { | } 2389]^cdufWfWfh\VhFNCJOJQJaJh\VhD(CJOJQJaJh\VhXf>*CJOJQJaJh\Vh>7>*CJOJQJaJh\VhXfCJOJQJaJhTd>*CJOJQJaJh\Vhe>*CJOJQJaJh\VhG BCJOJQJaJh\Vh1CJOJQJaJh\VhG B>*CJOJQJaJh\Vh@C>*CJOJQJaJ 5 } 2] g$ & p@ P !Bh1$^`Bgdu$ & p@ P !B<1$^`Bgd+5n' & p@ P !Bdhx1$^`Bgd9"% & p@ P !>dh1$^`>gd9"   PQuĵĦėĈyj[Lj[Lh\VhTCJOJQJaJh\VhtCJOJQJaJh\Vhm3PCJOJQJaJh\Vhs+CJOJQJaJh\VhCJOJQJaJh\Vho*CJOJQJaJh\VhhaCJOJQJaJh\VhD(CJOJQJaJh\VhG BCJOJQJaJh\VhVCJOJQJaJh\VhFNCJOJQJaJh\Vhz9CJOJQJaJ=>?1<ACvy{ⵦyyj[K>hu+>*CJOJQJaJh\Vhb >*CJOJQJaJh\VhCJOJQJaJh\Vh CJOJQJaJh\Vha\CJOJQJaJh\Vh@CJOJQJaJh\VhleCJOJQJaJh\Vh"CJOJQJaJh\VhhBCJOJQJaJh\Vh+QCJOJQJaJh\Vh%nCJOJQJaJh\VhG BCJOJQJaJh\Vh"CJOJQJaJ| .g' & p@ P !Bd1$^`Bgd)7% & p@ P !>dh1$^`>gdF"$ & p@ P !Bx1$^`Bgdm),$ & p@ P !Bx1$^`Bgd/x{|}   uv*+-.2]^dehiіцyцyцyj[[[h\Vh"BCJOJQJaJh\Vh]NCJOJQJaJhnc>*CJOJQJaJh\VhvNo>*CJOJQJaJh\VhvNoCJOJQJaJh\VhA/CJOJQJaJhu+>*CJOJQJaJh\Vh4f{>*CJOJQJaJh\VhG BCJOJQJaJh\VhCJOJQJaJh\VhG B>*CJOJQJaJ#iopstuzYZdĵӥyӥj[Lh\Vh6CJOJQJaJh\Vhp)CJOJQJaJh\Vh"CJOJQJaJh\Vh gCJOJQJaJh\VhG B>*CJOJQJaJh>*CJOJQJaJh\Vh g>*CJOJQJaJh\VhTCJOJQJaJh\Vhb;CJOJQJaJh\VhG BCJOJQJaJh\Vh*r CJOJQJaJh\VhlOCJOJQJaJ.t dG & P `0 p#h1$gdc% & p@ P !>dh1$^`>gd Tm$ & p@ P !Bx1$^`Bgd Tm' & p@ P !Bdh<1$^`BgdZ&' & p@ P !Bdh1$^`Bgd)7d )ȹة{l{]P]{l{A{h\Vh)CJOJQJaJh >*CJOJQJaJh\Vh aCJOJQJaJh\Vh8;CJOJQJaJh\VhG BCJOJQJaJ"h\VhG B56CJOJQJaJheL>*CJOJQJaJh\Vh Tm>*CJOJQJaJh\Vh TmCJOJQJaJhQhG B>*CJOJQJaJhQ>*CJOJQJaJhQCJOJQJaJh\VhlICJOJQJaJP'uPP$ & p@ P !h<1$^h`gd7$ & p@ P !h1$^h`gd ? & p@ P !h1$gd ?" & p@ P !>1$^`>gd%$ & p@ P !Bh1$^`Bgd?)*MNOPQ#$&'(*ŵ▉yjZMyjZMy>h\Vh&CJOJQJaJhs$>*CJOJQJaJh\Vh 6e>*CJOJQJaJh\Vh];aCJOJQJaJh\VhG B>*CJOJQJaJh#s>*CJOJQJaJh\Vh=D>*CJOJQJaJh\VhvbCJOJQJaJh?hG B>*CJOJQJaJh?>*CJOJQJaJh\VhA&C>*CJOJQJaJh\VhG BCJOJQJaJh\Vh1CJOJQJaJ*IJLMչ՞rcչTEh\VhxyCJOJQJaJh\Vh*#CJOJQJaJh\VhtCJOJQJaJh\Vh)CJOJQJaJh;&hG B>*CJOJQJaJh;&>*CJOJQJaJh;&CJOJQJaJh\Vh0VCJOJQJaJhtX>*CJOJQJaJh\Vh}oCJOJQJaJh\VhG BCJOJQJaJh\VhG B>*CJOJQJaJhs$CJOJQJaJ'JKL   "$%'(*+gd & p@ P !1$" & p@ P !h1$^h`gdvb$ & p@ P !hx1$^h`gdX   "#%&()+,./01789:;<BCDEFGHvw⿻|q|a|]h`{hn>h`{5>*OJQJaJh`{5OJQJaJhn>h`{5OJQJaJh.0JmHnHuhO hO0JjhO0JUh_hEIIh5OJQJaJh vjh vUh\VhnCJOJQJaJhG BCJOJQJaJh\VhG BCJOJQJaJh\Vh7YlCJOJQJaJ$+-./09:;FGH & p@ P !1$$ & p@ P !1$a$gd`{ &`#$gd_$ & p@ P !1$a$gdEIIgdh\VhG BCJOJQJaJh vI 0 00P:pI@PBP/ =!"#$8% Dps666666666vvvvvvvvv666666>6666666666666666666666666666666666666666666666666hH6666666666666666666666666666666666666666666666666666666666666666666866666662 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p(8HX`~8XV~ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@OJQJ_HmH nH sH tH D`D NormalCJOJQJ_HmH sH tH DA D Default Paragraph FontViV 0 Table Normal :V 44 la (k ( 0No List 8+8  Endnote TextCJ4@4 0Header  !:/: 0 Header Char CJOJQJ4 @"4 0Footer  !:/1: 0 Footer Char CJOJQJ.)`A. 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