(Attachment form 1)

	Application Form for Animal Use and Care, Laboratory Animal Research Center(LARC), Chungbuk National University

IACUC Review

• Please download an application form from LARC homepage (http://larc.cbnu.ac.kr/) each time.

• Please Principal investigator(PI) fill out the application form and submits it to LARC IACUC members

• Approval for Animal Use and Care by LARC IACUC members within at least 7 working days.

1. General Information for Principal investigator(PI) : Submit number :
PI name		Organization / Department		Position
Office phone number		Cellular phone number		e-mail
Research staff name		Organization / Department		e-mail
Emergency contact (cellular phone)		Role in project

Has this study been previously carried out ?

YES (        ), NO (         )

If the study has been previously carried out, please provide scientific justification for why it is necessary to repeat the experiment.

Financial Sponsor of the Study (Funding Individual or organization.)	Total budget
□ KOSEF (Korea Science and Engineering Foundation)	won
□ KRF (Korea Research Foundation)	won
□ KFDA (Korea Food and Drug Administration)	won
□ CBNU (oneself research expenses)	won
□ etc	won

2. Study Title :

3. Study Summary / objection or aim :

※ Scientific Description :

Briefly summarize (in less than three sentences) the aim(s) of the study and the

fermintion of human or animal health and the advancement of knowledge by this study.

※ General Description

Please use general terminology understandable by people outside your field

4. Type of animal experimental study :

□ Collection of biosample       □ Surgical Procedures         □ Irradiation

□ Infection                    □ Carcinogenesis             □ Behavior

□ etc (                                                                      )

5. Special Husbandry Requirements :

Briefly describe any special food, water, temperature, humidity, light cycles, caging type, and bedding requirements.

6. Total Project Period :

Date : 20  .    .    . ~ 20   .    .    .

7. Animals :
□ Mouse, □ Rat, □ Guinea Pig, □ Rabbit, □ Hamster, □ Dog, □ Cat, □ Pig, □ Gerbil, □ etc ( )
Species/Strain			Contributor
□ SPF(Specific Pathogen Free), □ CL(Clean), □ CV(Conventional), □ Germ Free, □ Gnotobiotic, □ non-identification
weigh : □g, □㎏		Age : weeks		pregnant : days		Total Number : □ ♂, □ ♀

9. Species rationale :
Please provide the rationale for the animal species chosen, insead of the use of non-mammalian, invertebrate species, or non-animal systems (e.g., cell or tissue culture, computerized models). A. Why is it necessary to use laboratory animals rather than in vitro methods, human studies, computer models or other methods ? B. Why is the animal species you have chosen most appropriate for your study ? List databases for the study recently performed as you refer.
Data base	Date of search	Reference title (Full name)	Keywords used
e.g., PUBMED MEDLINE SCIENCEDIRECT

10. Animal numbers justification :

(Justify in detail the total animal number including all mothers, pups and embryos of each species and strain requested ; animal necessary for statistical significance)

Please describe the consideration given to reducing the number of animals required for this study; this could include any in vitro studies performed prior to the proposed animal studies.  Please also provide information on how you arrived at the number of animals required.  If preliminary data is available and if relevant, please provide a power analysis or other statistical method used to determine the number of animals necessary.  For studies where a statistical method such as a power analysis is not appropriate (such as pilot studies, tissue collection), please provide a brief narrative describing how the requested animal numbers were determined to be necessary

11. Animal Restraint :

Will any animal be kept awake and restrained for long periods of time (Mark yes or no)? If yes, describe and justify composition of the animal lead to a condition that requires special care, such as a barrier housing, special diet, food or water restriction.

MARK : □  YES   ,  □  NO

IF YES, explain

A. Reason :

B. Length :

C. Conditioning procedure :

12. Reduction :
Provide evidence that you have reduced animal number as many as possible without jeopardizing statistical validity. List databases you searched and when, citations derived, and the keywords or search strategy. List other sources, such as journal articles and presentations.
Data base	Date of search	Reference title (Full name)	Keywords used

13. Refinements(Consideration of alternatives) :
Convince IACUC members that you have adequately explored alternative methods. Use techniques to minimize pain and distress. These are known as "refinements" to your protocol. List databases you searched and when, citations derived, and the keywords or search strategy. List other sources, such as journal articles and presentations.
Data base	Date of search,	Reference title (Full name)	Keywords used:

14. Replacement :
Provide evidence that you have considered replacing potential pain or distress-producing methods with other techniques (e.g., in vitro techniques, computer simulations, etc.). List databases you searched and when, citations derived, and the keywords or search strategy. List other sources, such as journal articles and presentations.
Data Base	Date of search,	Reference title (Full name)	keywords used:

15.  Keeping Animals in Non-LARC Facilities:

Will any animals be kept out of the LARC facility for more than 12 hours ?

(Mark yes or no)

MARK : □  YES   ,  □  NO

(If yes, give a reason that provide scientific justification for that need in the space below)

REASON :

16. Description of Experimental Design and Animal Procedures :

Describe Experimental Design, Animal Procedures, and sampling here

Describe Surgical Procedures here

etc

17. Pain or Distress Classification :

check in blank box

□ Classification B: Animals being bred, conditioned, or held for use in teaching, testing, experiments, research, or surgery, but not yet used for such purposes.

□ Classification C: Animals upon which teaching, research, experiments, or tests will be conducted involving no pain, no distress, or no use of pain-relieving drugs.  Euthanasia must precede any invasive procedure (i.e. tissue harvesting) to be in Classification C.

□ Classification D: Animals upon which experiments, teaching, research, surgery, or tests will be conducted involving accompanying pain or distress to the animals and for which appropriate anesthetic, analgesic, or tranquilizing drugs will be used.  Acute or terminal surgery is considered a painful procedure, which is alleviated by anesthesia.

□ Classification E: Animals upon which teaching, experiments, research, surgery (survival or non-survival), or tests will be conducted involving accompanying pain or distress to the animals and for which the use of appropriate anesthetic, analgesic, or tranquilizing drugs will adversely affect the procedures, results, or interpretation of the teaching, research, experiments, surgery, or tests and/or animals upon which teaching, experiments, research, surgery (survival or non-survival), or tests will be conducted resulting in permanent physiological impairment that may lead to chronic pain or distress.

18. Drugs to be used (except for euthanasia) - anesthetics, analgesics, tranquilizers, neuromuscular blocking agents or antibiotics:
Provide the following information about any of these drugs that you intend to use in this project. □ antibiotics, □ anesthetics, □ analgesics, □ tranquilizers, □ neuromuscular blocking agents, □ etc ( )
Drug	Dose (mg/kg)	Route	When and how often will it be given?

19. Postoperative and Postanesthesia Care :

Answer this question only if an animal will undergo survival surgery or general anesthesia for any survival purpose

a. Where will the animal be kept (room/building) until it recovers from anesthesia?

b. How often will the animal be observed until it recovers?

c. Who will observe the animal until it recovers? [Supply name(s)             ]

d. How will postoperative/post-anesthesia body temperature be maintained?

e. If the animal will not be kept in its own cage until fully recovered, explain why.

f. If skin sutures or clips are used, when will they be removed?

20. Endpoint criterion :

Describe endpoints that achieve the aims of the study and avoid unnecessary pain and distress. Include the criteria you will use to decide when to intervene or end animal use in the study, e.g., pain that cannot be controlled with analgesics, tumor size, and stage of disease. Interventions include euthanasia, treatment, or discontinuance of procedure.

21. Methods of euthanasia :
Even if your study does not involve euthanizing the animals, please provide a method that you would use in the event of unanticipated injury or illness. If anesthetic overdose is the method, please provide the agent, dose, and route.
Drug	Dose (mg/kg)	Route	In not usage of drugs, Describe methods of euthanasia here

22. Hazardous Materials : (Hazardous chemicals would include chemicals that are flammable, toxic, corrosive, or chemotherapeutic)
Infectious Agents? [ ] Yes, [ ] No	Material: [ ] Lab, [ ] Vivarium
Radioisotopes? [ ] Yes, [ ] No	Material: [ ] Lab, [ ] Vivarium
Chemical Carcinogens? [ ] Yes, [ ] No	Material: [ ] Lab, [ ] Vivarium
Recombinant DNA? [ ] Yes, [ ] No	Material: [ ] Lab, [ ] Vivarium
Hazardous Chemicals? [ ] Yes, [ ] No	Material: [ ] Lab, [ ] Vivarium

23. Biosafety in research staff :

If you plan to expose your animals to any of the following hazards, you must submit an   appropriate requisite biosafety or radiation safety forms

Biohazards to Humans (Mark Yes or no) : If yes, explain reason

MARK : □  YES   ,  □  NO

REASON :

Radiation hazards to Humans (Mark Yes or no) : If yes, explain reason

MARK : □  YES   ,  □  NO

REASON :

24. Personnel Qualifications : Personnel experience, Training and Occupational Health Certification of Research Staff (Include P.I.)
Name	Major title / Degree	Laborastory Animal Research Center education		etc
		general traning	specific training
		□	□
		□	□
		□	□
		□	□

◉  I certify that I will notify the IACUC regarding any unexpected results that impact animals. Any unanticipated pain, distress, morbidity or mortality will be reported to the attending veterinarian

◉ I assume full responsibility for compliance with such regulations for all personnel involved with this protocol.

◉ I certify that I have provided an accurate description of the animal care and use to be followed in the proposed research or teaching activity ; that I will notify the LARC IACUC in writing of any changes in this protocol and will await IACUC approval before proceeding with animal research/teaching.

date:           .       .

Principal Investigator :                          Signature

date:           .       .

LARC receiptor :                          Signature

LARC IACUC Commentary               Approval number :

Sang Hwan Hyun, D.V.M. Ph. D	Yun Bae Kim, D.V.M. Ph. D
Signature	Signature
Final Decision of this protocol: __________ Approved __________ Not Approved __________ Conditionally Approved Date of Action: ______/______/______	Final Decision of this protocol: __________ Approved __________ Not Approved __________ Conditionally Approved Date of Action: ______/______/______
Sang Yoon Nam, D.V.M. Ph. D	Head of LARC Beom Jun Lee, D.V.M. Ph. D
Signature	Signature
Final Decision of this protocol: __________ Approved __________ Not Approved __________ Conditionally Approved Date of Action: ______/______/______	Final Decision of this protocol: __________ Approved __________ Not Approved __________ Conditionally Approved Date of Action: ______/______/______