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1、实验动物伦理审查表Applicat ion Format for EthicaI ApprovaI for Research Involv i ng Animals申请日期： 年 月日 受理编号：批准文号：Appl. Date Y M D .IACUC Issue No.课题名称及编号Program and No.课题来源Sponsor课题负责人Name of Principal Investigator科室Department动物实验负责人Contact Person电话和信箱Contact. and Email参与动物实验操作人员姓名、相关专业证书编号，经验、培训、资质和能力的描述 Nam
2、e and certificate number, Description of experience/training/competency of the individuals carrying out the research.拟实验时间：年 月 日 至年 月 日Experimental period:YM DtoY MDAn-ma- to be used 拟使用动物信息动物来源Animal origin 许可证编号Certificate number质量合格证Certification of fitne有 口无品种/品系Breed/Strain大鼠rat小鼠mice裸鼠 nude mi
3、ce 兔rabbit犬dog灵长类primary animal转基因动物genetically modified animal口其他等级Gradecv CL SPF GF 其他数量只O体重gNumber ()Weightg月龄MAgemoon拟 使 用 动 物 信 息拟 使 用 动 物 实 验 的 详 细 信 息动物实验项目的目的、必要性、意义和如何设计以达成研究目标 Experimental objective, necessity and significance and how the program has been designed to achieve the objectives
4、 of the research.选择实验动物种类和数量的原因Reasons for the choice of species and numbers of animals to be used详细列出对动物可能造成的所有可预期的伤害，包括动物运输、每个 实验方案动物饲养方式、实验操作步骤中等可能产生伤害或不适的细 节以及拟采取的防控措施Description of the overall harms expected to be experienced by the animals-including details of the likely adverse effects of eac
5、h protocol, cage breeding and the steps which will be taken to control these adverse effects.主要观察指标 Main observation target伦理委员会审批意见仁慈终点或实验终结的指标Humane endpoint or experimental terminative indicator动物处死方法Death conduct非处死动物的处置方式Not for the death of the animal disposition口继续使用口Continue to use口保存的机构 Sav
6、e in the agency放生野外口 Release to the wild其他，详细说明DOthers,detailed description动物替代、减少动物用量、降低动物痛苦伤害的主要措施Major measure for 3R是否使用有毒(害)物质(感染、放射、化学毒、其他)Poisonous (harmful) material (infection, radiate, chemical poison and other) being used否No是 Yes说明：Declare声明：1.我将自觉遵守实验动物福利伦理相关法规和各项规定，同意接受伦理 委员会和实验动物室管理者的监
7、督与检查。2.本人保证本申请表中所填内容真实、详尽和易懂。Declaration: 1.1 will abide by the law and regulation stipulation , and accept the supervision and inspection by the committee and laboratory animal department o2. The information 1 have given is accurate, detailed and comprehensive.声明人:课题负责人签(章)Declarant:Signature (stam
8、p)of PI动物实验负责人签(章)Signature(stamp)of Director of animal experiment年月 日YM DApproval opinion of Committee主审委员签(章)Signature (stamp) of Presiding of Committee年月日YMD审查委员表决Inspection by members: Agree () Disagree ()主任委员签(章)Signature (stamp) of Chairman of Committee年 月 日Y M D申报说明：申报时，请提交本表一式两份及电子版。受理文号和批准文号由伦 理委员会填写。Notice: Submitting the Application Format in duplicate an a electronic edition.The Appl. No. and IACUC Issue No. are make out by Jury.