INSTRUCTIONS FOR MINOR MODIFICATION FORM COMPLETION BY

The UNIVERSITY of WESTERN ONTARIO – UNIVERSITY COUNCIL ON ANIMAL CARE MINOR MODIFICATION FORM INSTRUCTIONS FOR MINOR MODIFICATION FORM COMPLETION BY INVESTIGATOR OR DESIGNATE MODIFICATION FORMS PURPOSE  Major Modification – As required by the CCAC, all modifications to an approved Animal Use Protocol must be approved by the AUS office. The Major Modification form may be used to request all changes to the currently approved protocol. All major changes require AUS veterinary, community rep, and safety officer review prior to AUS approval. However, where a modification significantly changes the scope of the protocol, a full Animal Use Protocol submission will be requested. Minor Modification (This form) - A reduced and expedited Minor Modification form may be used to request changes to Titles, Funding, Personnel & their Training Requirements, Non-Genetically Altered Strains, Location/Housing, and Animal # Increase <100%. Protocol Transfer Modification - A Protocol Transfer Modification form may be used to request a protocol transfer involving previously approved animals, procedures, drugs and locations. 2 – 3 days may be required for review. Review timeframe depends upon the workload on the AUS office at the time the Minor Modification form is submitted. Electronic Authorization, including an approved Minor Modification form, will be sent via email. Paper copies will no longer be distributed; originals will remain within the AUS office.   MINOR MODIFICATION FORM AUTHORIZATION TIMEFRAME & METHOD   FORM COMPLETION & SUBMISSION:     Principal Investigator (PI) or PI Designate to complete this form via computer. PI must identify PI Designate within Section A. Investigator Declaration; PI approval for this transfer is indicated via completion of Section A. Investigator Declaration. Save the form file using the following file name structure: Protocol # PI Last Name mm/dd/yy MINMOD. o E.g. 2008-000 Copeman 05.06.08 MINMOD Submit completed form to acvs@uwo.ca. Submission by Designate must involve email ‘copy – c.c.’ to PI. d0f5da58-350d-49ea-9f16-2bfc42df796d.doc 2/26/2009 Page 1 The UNIVERSITY of WESTERN ONTARIO – UNIVERSITY COUNCIL ON ANIMAL CARE MINOR MODIFICATION FORM A. INVESTIGATOR DECLARATION I. All animals used in this research project will be cared for in accordance with the recommendations of the Canadian Council on Animal Care and the requirements of the provincial legislation entitled, "The Animals for Research Act," of the Province of Ontario. II. I confirm that the changes associated with this Protocol Renewal, in addition to previous form submissions associated with this protocol, accurately represents the proposed animal use. III. I will ensure that any individual who will perform any animal-related procedure(s) within this protocol will complete all related mandatory training AND will be made familiar with the contents of this document. 1. I support the above declaration - YES Today’s Date (mm/dd/yy) 2. By checking ‘YES’ in this section, I authorize the submission of this form and its electronic delivery to acvs@uwo.ca YES NO 3. I authorize (PI Designate) to submit this form and to receive a copy of authorization via email on my behalf. Today’s Date (mm/dd/yy) AUS APPROVAL - AUS Office Use OnlyVeterinary Authorization by Click Here Authorization Date (mm/dd/yy) Signature: B. PROTOCOL/INVESTIGATOR INFORMATION I. PROTOCOL INFORMATION Investigator Name: Protocol Title: Current Protocol #: This is a new title II. INVESTIGATOR CONTACT INFORMATION Department: Email Address: d0f5da58-350d-49ea-9f16-2bfc42df796d.doc 2/26/2009 Page 2 The UNIVERSITY of WESTERN ONTARIO – UNIVERSITY COUNCIL ON ANIMAL CARE MINOR MODIFICATION FORM Office Phone: Lab Phone: C. MINOR MODIFICATION PURPOSE - Mandatory Completion Required Use the drop-down lists to indicate all overall change types requested by this MINOR modification form Provide Justification & Other Details Not Added to Related Sections Area of Change Click Here Click Here A change Click Here in… Click Here Click Here For lengthy descriptive, enter details here: D. NEW FUNDING SOURCE INFORMATION FUNDING SOURCE #1 Funding Source Type: Click Here Institution Administering Funding: Funding Source Name: Funding/Grant Number: OR Applied For: Related Account # (Speed Code or ROLA #): Does this Source Conduct Peer Review? Yes No Unsure Granting agency requires submission confirmation Yes No If Yes, Due Date: mm/dd/yy / / Grant Title: Same as Protocol Title, or FUNDING SOURCE #2 Funding Source Type: Click Here Institution Administering Funding: Funding Source Name: Funding/Grant Number: OR Applied For: Related Account # (Speed Code or ROLA #): Does this Source Conduct Peer Review? Yes No Unsure Granting agency requires submission confirmation Yes No If Yes, Due Date: mm/dd/yy / / Grant Title: Same as Protocol Title, or d0f5da58-350d-49ea-9f16-2bfc42df796d.doc 2/26/2009 Page 3 The UNIVERSITY of WESTERN ONTARIO – UNIVERSITY COUNCIL ON ANIMAL CARE MINOR MODIFICATION FORM E. RESEARCH STAFF & THEIR TRAINING REQUIREMENTS – Mandatory Completion Complete for ALL Staff Working Within This Specific Protocol NO NEW/CHANGES TO Research Staff & Their Training Requirements (Go to E.) TRAINING INFORMATION CCAC Mandated Training Requirements – All personnel working with live animals require CCAC mandated training including the ‘Basic Animal Care & Use Web-CT Course’ and related hands-on ‘Workshops ‘. Completion of the ‘Basic Animal Care & Use Web-CT Course’ once every 5 years is mandatory for ALL personnel, including the Principal Investigator. The Animal Use Subcommittee will be informed of all personnel with incomplete training beyond 1 month of notice. Workshop Enrolment Detail – The ‘Workshop’ requirements are determined by the species and procedures associated with each individual listed below. All personnel listed below will be contacted directly via the email address listed below for auto-enrolment in all ‘Workshop’ requirements. Previous hands-on ‘Workshops’ attended at another research institution may be accepted; please submit training documentation with this form. For additional training requirement detail and associated costs, go to http://www.uwo.ca/animal/website/VS/Content/Teaching_and_Courses.htm COMPLETE ALL COLUMNS BELOW PER PERSON EMAIL Address ROLE Researcher If ‘YES’ to HANDS-ON ANIMAL WORK, Complete This Section PER SPECIES PROCEDURES PER SPECIES SPECIES One Species Per Row Use an Additional Row for Each Species Click Here Click Here Click Here Click Here Click Here FIRST NAME Repeat For Each Species Used LAST NAME Repeat For Each Species Used *Mandatory Field* UWO & Affiliated Institution Emails Preferred Staff Student HANDS ON Animal Work? YES or NO Expected START DATE mm/dd/yy 1=Basic Handling 2=Health Monitoring 3=Blood Collection 4=Injections 5=Anaesthesia 6=Surgery-Recovery 7=Surgery-Non-Recovery 8=Euthanasia/Post Mortem 9=Other, Provide Detail Below 1 Principal Investigator 2 3 4 5 6 7 8 9 Click Click Click Click Click Click Here Click Here Click Here Click Here d0f5da58-350d-49ea-9f16-2bfc42df796d.doc 2/26/2009 Page 4 The UNIVERSITY of WESTERN ONTARIO – UNIVERSITY COUNCIL ON ANIMAL CARE MINOR MODIFICATION FORM Click Here Click Here Click Here Click Click Click Click Here Click Here Click Here PROCEDURE #9 DETAIL EMERGENCY AFTER HOURS CONTACT NAMES & NUMBERS - NO LAB PHONE NUMBERS PRIMARY EMERGENCY CONTACT LAST NAME & INITIAL : SECONDARY EMERGENCY CONTACT LAST NAME & INITIAL : PRIMARY EMERGENCY CONTACT NUMBER (HOME OR CELL) : SECONDARY EMERGENCY CONTACT NUMBER (HOME OR CELL) : STAFF REMOVALS F. ANIMAL REQUIREMENTS Animals listed below should pertain to Experimental/Teaching/Breeding Groups identified in Section D.5.1. and should include ALL animals required for the REMAINDER of the Animal Use Protocol 4-YEAR lifetime. Animal number calculations should also include all anticipated weaned, vendor-donated, and noncommercial animal receipts (e.g. protocol and/or external facility transfers) STRAIN &/or OTHER SPECIES DETAIL For Rodents, Also Provide Vendor Stock # AGE or WEIGHT & SEX ANIMAL NUMBER REQUESTED ANIMAL SOURCE Pick All That Apply SPECIES GROUP ID # Click Here Click Here Click Here Click Here Click Here Click Here All ID # All ID # All ID # All ID # All ID # All ID # or or or or or or Click Here; Click Here; Click Here Click Here; Click Here; Click Here Click Here; Click Here; Click Here Click Here; Click Here; Click Here Click Here; Click Here; Click Here Click Here; Click Here; Click Here d0f5da58-350d-49ea-9f16-2bfc42df796d.doc 2/26/2009 Page 5