Howard University Proposal for Laboratory Vertebrate Use in Research, Teaching or Testing Form IACUC C Use this form for minor changes to a research proposal. Do Not Use this form if there are significant changes in animal care and use. For significant changes use Form IACUC A Proposal for Laboratory Vertebrate Use in Research, Teaching or Testing. See Instructions for completing the IACUC Forms at www.huiacuc.howard.edu . Sections of this form will expand to accommodate text as needed. Note: Incomplete, hand-written or unsigned forms will be returned. For assistance in completing this form call the IACUC Office at 202 865 8353 or email Marline BrownWalthall at marline.brownwalthall@howard.edu. The IACUC Office Address is IACUC, Howard University Office of Research and Regulatory Compliance, Howard University Research Building (HURB-1), 1840 7th Street, NW, Room 215, Washington, DC 20001. If required click “enable content” and “edit document” to access input fields	For Committee Use Only (Revised 07/2017)
Date Received:
IACUC No.:
Document Type:	Addendum
FCR	Date Reviewed
FCR Approval Date
Assigned to Scientific Merit Rev	Date
Assigned to DMR	Date
DMR Approval Date
RSC	NA Pending	Approval Date
IBC	NA Pending	Approval Date
Final Approval Date
Expiration Date
No. Animals Approved This Period
USDA Category:	C D E
Notes:

Protocol No.	Expiration	Funding Source
Proposal Title
Principle Investigator Information
Prefix	First Name	Middle Init	Last Name	Dept	Phone	Fax	Email
Identify species (using drop-down menu) and indicate (√) if animal is a USDA-covered species (USDACS) or Endangered (ENDG)
Species1	USDACS	ENDG	Species2	USDACS	ENDG	Species3	USDACS	ENDG

1. A. Animal Use Information. Skip this section if there will be no changes in animal numbers. Check here and add supplemental animal numbers page(s) page if you are using more than 3 species or strains. Greater than a 15 % increase requires Full Committee Review.

Total Animals Per Year and Total Animals for All Years Per Breed or Strain(Rodents) Under Breed/Strain list each strain separately and enter entire strain genotype; add an abbreviation if desired.	II. Average No. Housed Simultaneously	III. Average Housing Days Per Animal
Species 1	Breed or Strain(s)	HOW MANY AT A TIME?	AVERAGE TO BE HOUSED DAILY?
Total Animals Per Year for each species of animal [See instructions above (*).]	Year	Year	Year	Year	Year	Total for Years -	6. Current Approved (if Not New) or Requested (New)	7. Change Request (Enter 0 if New)	8. Current Approved (if Not New) or Requested (New)	9. Change Request (Enter 0 if New)
Indicate the year or 12-month approval period for which approval to add or use animals applies
1. No. Approved\Requested	0	0	0	0	0	0	0	0	0	0
2. Additional No. Requested	0	0	0	0	0	0	Numbers may be entered in Rows 1, 2 and 4 for Years 1 thru 5. Numbers are automatically calculated in Rows 3 and 5. If there is a delay in calculation after numbers are entered, double click any number in Rows 1, 2 or 4 to the left of the last number entered.
3. New Total (Add 1 + 2)	0	0	0	0	0	0
4. No. Used To Date	0	0	0	0	0	0
5. No. Remaining for Use (Subtract 4 minus 3)	0	0	0	0	0	0
INDICATE NUMBER OF ANIMALS YOU PLAN TO USE DURING OR WITHIN THIS 12-MONTH APPROVAL PERIOD (BE SURE TO ADD REMAINING ANIMALS PREVIOUSLY APPROVED IF YOU STILL PLAN TO USE THEM FOR THIS APPROVAL PERIOD) My request for or within this 12 month approval period is:
For This Approval Period Only Enter Animal Numbers	Year 1 request or number of animals already approved for this 12 month approval period	Number of new animals to be added	Carryover [from previous year or years (if applicable)	Total:
0	0	0	0
Comments:

Total Animals Per Year and Total Animals for All Years Per Breed or Strain(Rodents) Under Breed/Strain list each strain separately and enter entire strain genotype; add an abbreviation if desired.	II. Average No. Housed Simultaneously	III. Average Housing Days Per Animal
Species 2	Breed or Strain(s)	HOW MANY AT A TIME?	AVERAGE TO BE HOUSED DAILY?
Total Animals Per Year for each species of animal [See instructions above (*).]	Year	Year	Year	Year	Year	Total for Years -	6. Current Approved (if Not New) or Requested (New)	7. Change Request (Enter 0 if New)	8. Current Approved (if Not New) or Requested (New)	9. Change Request (Enter 0 if New)
Indicate the year or 12-month approval period for which approval to add or use animals applies
1. No. Approved\Requested	0	0	0	0	0	0	0	0	0	0
2. Additional No. Requested	0	0	0	0	0	0	Numbers may be entered in Rows 1, 2 and 4 for Years 1 thru 5. Numbers are automatically calculated in Rows 3 and 5. If there is a delay in calculation after numbers are entered, double click any number in Rows 1, 2 or 4 to the left of the last number entered.
3. New Total (Add 1 + 2)	0	0	0	0	0	0
4. No. Used To Date	0	0	0	0	0	0
5. No. Remaining for Use (Subtract 4 minus 3)	0	0	0	0	0	0
INDICATE NUMBER OF ANIMALS YOU PLAN TO USE DURING OR WITHIN THIS 12-MONTH APPROVAL PERIOD (BE SURE TO ADD REMAINING ANIMALS PREVIOUSLY APPROVED IF YOU STILL PLAN TO USE THEM FOR THIS APPROVAL PERIOD) My request for or within this 12 month approval period is:
For This Approval Period Only Enter Animal Numbers	Year 1 request or number of animals already approved for this 12 month approval period	Number of new animals to be added	Carryover [from previous year or years (if applicable)	Total:
0	0	0	0
Comments:

Total Animals Per Year and Total Animals for All Years Per Breed or Strain(Rodents) Under Breed/Strain list each strain separately and enter entire strain genotype; add an abbreviation if desired.	II. Average No. Housed Simultaneously	III. Average Housing Days Per Animal
Species 3	Breed or Strain(s)	HOW MANY AT A TIME?	AVERAGE TO BE HOUSED DAILY?
Total Animals Per Year for each species of animal [See instructions above (*).]	Year	Year	Year	Year	Year	Total for Years -	6. Current Approved (if Not New) or Requested (New)	7. Change Request (Enter 0 if New)	8. Current Approved (if Not New) or Requested (New)	9. Change Request (Enter 0 if New)
Indicate the year or 12-month approval period for which approval to add or use animals applies
1. No. Approved\Requested	0	0	0	0	0	0	0	0	0	0
2. Additional No. Requested	0	0	0	0	0	0	Numbers may be entered in Rows 1, 2 and 4 for Years 1 thru 5. Numbers are automatically calculated in Rows 3 and 5. If there is a delay in calculation after numbers are entered, double click any number in Rows 1, 2 or 4 to the left of the last number entered.
3. New Total (Add 1 + 2)	0	0	0	0	0	0
4. No. Used To Date	0	0	0	0	0	0
5. No. Remaining for Use (Subtract 4 minus 3)	0	0	0	0	0	0
INDICATE NUMBER OF ANIMALS YOU PLAN TO USE DURING OR WITHIN THIS 12-MONTH APPROVAL PERIOD (BE SURE TO ADD REMAINING ANIMALS PREVIOUSLY APPROVED IF YOU STILL PLAN TO USE THEM FOR THIS APPROVAL PERIOD) My request for or within this 12 month approval period is:
For This Approval Period Only Enter Animal Numbers	Year 1 request or number of animals already approved for this 12 month approval period	Number of new animals to be added	Carryover [from previous year or years (if applicable)	Total:
0	0	0	0
Comments: If adding new species or strains of animals explain and justify the reason for the change Be sure to justify any increase in the number of animals. If the increase is greater than 15% Full Committee is Required.

V. List name(s) of all animal handlers(s) added to or deleted from this project below:
Staffing Change	Name	Completed LATA Online Training and Certification	Years of Experience With Relevant Species
Yes	No
Added
Added
Added
Added
Added
Deleted
Deleted
Deleted
Deleted
Deleted
Information Needed if Adding Staff: (1) Indicate their animal research experience (briefly); (2) Describe the procedures and duties they will perform on the protocol, (3) Identify the research staff person who will train them in protocol specific procedures they have never performed (Document training if applicable: individual trained, trainer, procedure trained to perform, date of training and location of training).

V. List any minor changes to be employed for animal use or care below. Be sure to explain and justify the reason for the change. Be sure to address all animal welfare concerns and associated monitoring and intervention relative to adding any new procedure.

I certify that this form is completed truthfully, that I and all persons who handle animals on this project are or will be appropriately trained, that the IACUC will be notified before any changes are made in animal use or care, that this study will be conducted humanely in accordance with University and applicable federal regulations, and that a reasonable good-faith effort was made to assure that the proposal activities do not unnecessarily duplicate previous experiments. Applicable IACUC guidelines will be followed.
Principal Investigator (Print or Type Name)	Principal Investigator Electronic or Standard Signature	Date

Separate Sheet for Progress Report: