Animal Care and Use Review Form

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Animal Care and Use Review Form

Office use only Protocol # Date Approved Date Expires

The University of Iowa Animal Care and Use Review Form

University policy and federal regulations require a review of projects for humane treatment and safe use of vertebrate animals in research and teaching by all University of Iowa staff on or off campus. At the University of Iowa, the review is conducted by the Institutional Animal Care and Use Committee (IACUC). The U.S. Public Health Service requires verification of IACUC approval of animal care and use for funded projects before monies will be released for use. For projects funded by non-PHS agencies; verification of IACUC approval of animal care and use generally must occur within 60 days after submission of an application or proposal. Six weeks is required to process this application. Please complete all parts of the attached form. Additional information to clarify some questions can be accessed by clicking on the icon adjacent to the question. This application must be completed on a word processor, and submission must include a signed hardcopy and computer file (Word, Word Perfect or Adobe). E-mail the file to [email protected]. For externally sponsored projects, please provide a hardcopy of the Research Plan portion of the grant/contract application. Please return the signed hardcopy of this form and the Research Plan portion of the grant/contract to the OAR, 400 Medical Laboratories. This document is best viewed in “Print Layout”. It is recommended, that first-time users of this form schedule an appointment with the IACUC coordinator by sending an e-mail to [email protected] or calling 5-7985.

I. Principal Investigator: Name Department Campus Address Telephone # E-mail address Lab phone Lab Address(Building, Rm#) Please copy and paste this table to add additional personnel.

Co-Investigator(s): Name Department Campus Address Telephone #: E-mail address Please copy and paste this table to add additional personnel.

II. Project Information: 1 (Revised 1 6/11/03) Please download the latest form at http://research.uiowa.edu/animal/?get=forms Project title: (Use the same title as the grant application; For Center, PPG, or Training Grant, use subproject title.)

Grant Application Deadline Project Start Date

III. Funding Information: Answer all Three Questions Yes or No

Yes No External funding expected: (Please provide a hard copy of research plan portion of grant) Yes No Research Plan attached: If not attached please explain: Yes No Internal funding expected;(If YES, Departmental review and assurance are required [see VII])

Funding Agency Name Funding Agency Number (if known)

IV. Type of project: Yes No New Project Yes No Renewal Previous ACURF# Yes No Duplicate Submission Previous ACURF # Yes No Instructional project Yes No Part of training grant: Program Dir. Yes No Part of center or program Program Dir project;

V. SPECIAL CONCERNS Answer ALL of the following: Please read the material hyperlinked to any positive response: Yes No Instructional use of animals (teaching course or training class) Yes No Survival surgery Yes No Hazardous chemicals, Biological agents, Recombinant DNA (including production of transgenic animals), other biohazardous agents Yes No Death as an endpoint (i.e. LD50, tumor growth). Yes No Custom antibody production by outside vendor Yes No Production of monoclonal antibodies using ascites method Yes No Use of Complete Freund's Adjuvant If you answer yes to any of the above questions click on the associated link to obtain additional information

2 (Revised 1 6/11/03) Please download the latest form at http://research.uiowa.edu/animal/?get=forms VI. PROJECT DESCRIPTION

1. If this is an initial application summarize in language that a high school student can understand, the aims and objectives of this project including its long-term goals and briefly explain the relevance this work will have to human or animal health, the advancement of knowledge or the good of society. The grant abstract may not be used. If animals in this proposal will be used for instructional purposes also list the course objectives. If the answer is longer than one page the contents in the box often will not all appear. To enter a longer answer click in the box, then go to the top menu, click on “Table” then click on “Convert” and then click on “Table to text”.

If this is a renewal application summarize in language that a high school student can understand, what was learned during the initial approval and explain how the results influence the continuation of the project. Briefly explain the relevance this work will have to human or animal health, the advancement of knowledge or the good of society. The grant abstract may not be used. If animals in this proposal will be used for instructional purposes also list the course objectives. If the answer is longer than one page the contents in the box often will not all appear. To enter a longer answer click in the box, then go to the top menu, click on “Table” then click on “Convert” and then click on “Table to text”.

QUESTIONS SPECIFICALLY MANDATED by Regulations 2. a. You must perform database searches unless compelling justification can be made without it. A standard literature search is the usual method to demonstrate this project is not “unnecessarily duplicative” and to search for “alternative experimental approaches.” To search for alternatives, match the basic problem under investigation (e.g, heart failure, hypertension, arrhythmia) to terms or phrases like “animal testing alternatives”, simulations, in vitro, or cell culture. If a database search was performed please answer ALL four of the following questions.

Database(s) Searched: Date of Search (must be within two months of submission) Years Searched (range): Search Terms and/or Search Strategy

b. If a literature search is NOT performed, provide a narrative to justify why this project is not duplicative and that no acceptable alternatives are available.

c. Comment upon the potential application of any identified alternatives.

3 (Revised 1 6/11/03) Please download the latest form at http://research.uiowa.edu/animal/?get=forms d. Describe what consideration has been given to the following alternatives : -Reducing the numbers of animals required -Modifying a procedure to lessen or eliminate pain or distress to the animal -Use of a non-mammalian or invertebrate species -Use of a non-animal system (cell or tissue culture, computer model, mathematical model, etc.)

3. Is this project unnecessarily duplicative?

No Proceed to Question 4. Yes Proceed to Question 4.

PERSONNEL: 4. Personnel: Please provide the following information for all personnel involved in this project who will handle animals, including investigators, technicians and students. Describe the relevant training and experience of each person. If personnel do not have experience, describe how they will be trained. Participation in the University Employee Health Clinic ((UEHC) Clinic A; Boyd Tower; 356-3632) program for animal users is determined on a case by case basis for all persons having any contact with animals or animal tissues. List all individuals having contact with animals, the species involved and a brief description of the degree of contact (e.g. rodents, less than 2 hours/week). Include their University address, phone number, e-mail address, so that they can be contacted by the UEHC regarding enrollment in the program. Principal Investigator/Coinvestigators: Please complete for each investigator listed in I. (first page) Name: Describe Training: Has this person taken the University Yes online training module on Policies/Regulations?  Describe related experience with techniques Proposed: Describe how individual will be trained if no prior relevant training or experience Is this person performing Survival Surgery surgery? Nonsurvival surgery Not Applicable Describe exposure to each species that will occur during

4 (Revised 1 6/11/03) Please download the latest form at http://research.uiowa.edu/animal/?get=forms performance of this proposal. Please copy and paste this table to add additional investigators

Technical Personnel Name: Address: Dept: Phone #: E-mail address: Describe Training: Has this person taken the University Yes online training module on Policies/Regulations? Describe related experience with techniques Proposed: Describe how individual will be trained if no prior relevant training or experience Is this person performing Survival Surgery surgery? Nonsurvival surgery Not Applicable Describe exposure to each species that will occur during performance of this proposal. Please copy and paste this table to add additional personnel. NOTE: All personnel are required to take the Online course for “Policies/Regulations” and pass the associated quiz. (http://courses2.uiowa.edu:8900/public/AUEC/index.html)

ANIMAL Information 5. Animal species (common name)

Strain (if applicable) Describe the biological characteristics of each species that are essential to the proposed study 5 (Revised 1 6/11/03) Please download the latest form at http://research.uiowa.edu/animal/?get=forms Please copy and paste this table to add additional species/strains. Guidelines for proper nomenclature:

6. a. Approximately how many of each species will be used? You must include the total number of each species to be used over the three year duration of this proposal. This approval is for a maximum of three years. Do not count rodents that are not weaned. [NOTE: U.S. Government Principles for the Utilization and Care of Vertebrate Animals used in Testing, Research, and Training: III. The animals selected for a procedure should be of an appropriate species and quality and the minimum number required to obtain valid results. Species/ Strain Total

Please copy and paste this table to add additional species/strains. b. Describe how the number of animals needed for the study was determined. When appropriate, provide the number and type of experimental and control groups in each experiment, the number of experiments planned, and the number of animals in each group. The Guide states that whenever possible, the number of animals requested should be justified statistically. A power analysis is strongly encouraged to justify group sizes when appropriate. If the answer is longer than one page the contents in the box often will not all appear, to solve this problem click in the box then go to the top menu, click on “Table” then click on “Convert” and then click on “Table to text”. c. What is the source of the animals? Yes No Via the OAR Yes No Breeding colony in house d. Are Transgenic Animals utilized in this study? No Proceed to Question 7. Yes e. Does expression of the transgene/knockout phenotype result in pain/distress? No Proceed to Question 7. Yes It is mandatory that you answer Question 23 even if you answer Yes to Question 18 or 20.

7. Will the animals used in this study be subjected to any of the following : Yes No The animal(s) utilized in this study will have already been used in a previous study (non-naïve animals)? Yes No The same animal(s) used in this study may be used in a future? If yes to either of the above, please explain.

Note: Prior Committee approval is required for each of the above.

6 (Revised 1 6/11/03) Please download the latest form at http://research.uiowa.edu/animal/?get=forms 8. Animal Housing Location: Yes No University of Iowa Animal Care Unit Yes No Veterans Administration Research Facility Yes No Other: Please describe

9. Will animals be kept outside of the OAR animal quarters for longer than 12 or 24 hours No; Proceed to next question > 12 hours Building and Room # > 24 hours Building and Room #

If housed outside of OAR for > 24 hours please justify this requirement:

10. Will any special housing conditions be required for this project (lighting, feed, special caging, biological containment, etc.)? No; Proceed to Next Question Yes Please Specify

11. Do you request that rodents be housed in wire bottom cages? No or Not Applicable; Proceed to Next Question Yes; Please Justify 12. Do you request that nonhuman primates be excluded from the University of Iowa’s “Psychological Enrichment Program”? This program is designed to provide an enriched environment including social interactions among primates in use at the University. No or Not Applicable; Proceed to Next Question Yes; Please Justify 13. Do you request that dogs be excluded from the University of Iowa’s “Canine exercise Program”? No or Not Applicable; Proceed to Next Question Yes; Please Justify

HAZARD USE

14. Does this study utilize rDNA in vivo AND the animals are returned to the Animal Care Unit after exposure? No or Not Applicable; Proceed to Next Question Yes; Specify rDNA

7 (Revised 1 6/11/03) Please download the latest form at http://research.uiowa.edu/animal/?get=forms If yes, please complete and submit rDNA application to the Health Protection Office, available online or contact the Health Protection Office (HPO) at 335-8501. If an approval has already been received, please note approval: rDNA approval number

NOTE: If rDNA is used AT ALL (whether in animals or not) it’s use must be approved by the Institutional Biosafety Committee (IBC). Approval of this Animal Care and Use form does not approve the use of rDNA. rDNA use can only be approved by the IBC which is coordinated through the Health Protection Office (335-8501).

15. Are any of the substances listed in 15.a. used in this project? No or Not Applicable; Proceed to Question 16. Yes; Please complete 15a. & 15.b.

a. Substance Specify Substance Human blood, blood products, tissues Animal cells or extracts (from sources outside the OAR barrier facility) Non-sterile biological fluids Other Biological agents (other than rDNA, e.g. infectious agents) Carcinogens Hazardous chemicals Radioactive materials

b. Are any of the substances listed in 15.a. introduced into animals that are returned to the Animal Care Unit ALIVE: No or Not Applicable; Proceed to Question 15.e. Yes; Please complete 15.c.

c. Please complete and attach a containment protocol to this ACURF. Prior to initiation of this protocol, inform the OAR when use of the hazardous agent/material is pending to ensure the protection of OAR personnel. Forms are available at :

Have you appended a containment protocol? Yes; Proceed to Question 15.e. NO; Please complete 15.d.

d. If a containment protocol is NOT necessary please provide your rationale:

8 (Revised 1 6/11/03) Please download the latest form at http://research.uiowa.edu/animal/?get=forms e. Could any of the hazardous substances listed in 15.c.contaminate Animal Caging? No; Proceed to Question 16. Yes; Please complete 15.f.

f. If NOT already described in a submitted containment protocol (15.c.) please describe how you will decontaminate caging or equipment before returning it to the Animal Care Unit.

EXPERIMENTATION

16. Describe fully the method of euthanasia that will be employed for each species . a. Method

Species Chemical Agent Not applicable: Dose Route Physical Method Not applicable: Please copy and paste this table to add additional methods/species.

b. Scientific justification must be provided to perform euthanasia by a Physical method in an UNanesthetized or UNsedated animal. Not applicable (Proceed to Question 17. Scientific justification

17. Are tissues collected before euthanasia? If tail samples are taken for genetic analysis please indicate here and review IACUC guidelines No; Proceed to Question 18. Yes; Please list tissues harvested

18. Is the “only” procedure: euthanasia performed followed by harvest of tissues? No; Proceed to Question 19. Yes; You are finished; you do not need to complete the rest of the form

19. Will any procedures (surgical or non-surgical) require anesthesia? Anesthetic dosages can be found at this link No; Proceed to Question 20.

9 (Revised 1 6/11/03) Please download the latest form at http://research.uiowa.edu/animal/?get=forms Yes

a. Preanesthetic agent(s), dosage and route Species Drug (e.g. Atropine) Dosage (mg/kg) Route (IV, IM, SQ, IP) Please copy and paste additional tables if needed. b. Anesthetic agent(s), dosage and route Species Drug (e.g. Pentobarbital) Dosage (mg/kg) Route (IV, IM, SQ, IP) Please copy and paste additional tables if needed.

c. For prolonged procedures how will anesthesia be maintained?

d. How many times will anesthesia be required for each animal during the study ?

e. Describe the methods used to monitor the state of anesthesia and general well being :

f. Will paralytic agents be employed? No; Proceed to 19.g. Yes; Name of agent Explain why it is necessary to use this agent Explain how the animals will be monitored to insure adequate anesthesia

g. Is the proposed postprocedural and postanesthesia monitoring in accordance with IACUC recommendations? Yes; Proceed to 20. No; Specify the procedures that will be utilized below

20. Is the “only” procedure performed the harvest of tissue and/or body fluids under anesthesia followed by euthanasia? No; Proceed to Question 21. Yes; You are finished; you do not need to complete the rest of the form 10 (Revised 1 6/11/03) Please download the latest form at http://research.uiowa.edu/animal/?get=forms 21. Will antemortem blood samples be taken? No; Proceed to Question 22. Yes Species Route Amount # of collections Interval between collections Will blood collection be performed under anesthesia? Yes; Anesthesia should be described in answer to Question 19. No Please copy and paste additional tables if needed.

22. Is any procedure (including survival surgery) likely to cause pain or distress (e.g. any procedures that would reasonably be expected to cause pain or distress in a human)? Common analgesic dosages can be found at this link Do not provide anesthetic regimens; these are already described in Question 19. No; Proceed to Question 23. Yes Species Identify Painful Procedure Methods to alleviate pain/distress Justification for not providing relief from pain/distress Please copy and paste additional tables if needed.

23. Are there predictable adverse pre- or post-procedural events that may occur? No; Proceed to Question 24. Yes; Please describe event below and indicate how it will be humanely managed to minimize discomfort to the animal

Please copy and paste additional tables if needed.

24. Will food and/or water be restricted? No; Proceed to Question 25. Yes What is restricted? Food Water Species Length of restriction Interval between restrictions 11 (Revised 1 6/11/03) Please download the latest form at http://research.uiowa.edu/animal/?get=forms Monitoring during restriction Justify restricting food and/or water Please copy and paste additional tables if needed.

25. Will animals be restrained by tethers, stanchions, metabolism cages, etc.? No; Proceed to Question 26. Yes Species Method of restraint Duration of restraint Frequency of restraint Monitoring during restraint Acclimation of animal to restraint Justify restraint Please copy and paste additional tables if needed.

26. Will survival surgical procedures be employed? (Disruption of any integumentary surface of a living animal by any means other than a hypodermic needle, biopsy needle, ear punch, or tail snip is considered surgery. All surgical procedures must be described in Question 27.) NOTE: If survival surgery is performed it must be done using aseptic technique. Provide a description of the surgery in your answer to Question 27; describe the anesthetic regimen in your answer to Question 19 and describe your analgesic regimen in your answer to Question 22. No; Proceed to Question 27 Yes; Proceed to 26.a.

a. Will “multiple” survival surgeries be performed on the same animal? No; Proceed to Question 26.b. Yes; You must provide a detailed scientific justification as required by Federal regulations

b. Where will the survival surgery be performed? Bldg: Room:

c. Describe the postoperative care, fluids, physical support methods and postoperative monitoring given to the animals. Species Monitoring provided Please copy and paste additional tables if needed.

d. Is the proposed postprocedural and postanesthesia monitoring in accordance with IACUC recommendations? Yes;

12 (Revised 1 6/11/03) Please download the latest form at http://research.uiowa.edu/animal/?get=forms No; Specify below the procedures that will be utilized

Please copy and paste additional tables if needed.

e. How are the instruments sterilized? Steam Sterilization Ethylene oxide Chemical Please answer next the question in the table and review sterilization IACUC guidelines Name of sterilant

f. How do you insure that proper sterilization has occurred (check all that apply) All sterilization is performed by University Hospitals Central Sterilizing Integrator strips on inside of steam/ethylene oxide sterilized pack Indicator on outside of steam/ethylene oxide sterilized pack

g. Does the surgeon utilize the following during surgery? Yes No Sterile gloves If NO Why Not? Yes No Sterile gown If NO Why Not? Not required for rodent/ectotherm surgery Other reasons Yes No Face mask If NO Why Not?

27. For each distinct procedure, describe the manipulations that will be performed (including surgery) and the order in which they will be performed. Include time frames and intervals for the sequence of procedures. Unless listed elsewhere in this document, describe all drugs (including test substances) administered during the study as well as the dosage, route, and frequency. Procedures that will be performed after the animal has been euthanized need not be described. (Describe the procedures in enough detail so that reviewers will be able to determine what is actually being done to the animal. You DO NOT need to re-describe in detail procedures addressed in previous Questions (e.g anesthesia, euthanasia) If the answer is longer than one page the contents in the box often will not all appear. To enter a longer answer click in the box, then go to the top menu, click on “Table” then click on “Convert” and then click on “Table to text”.

13 (Revised 1 6/11/03) Please download the latest form at http://research.uiowa.edu/animal/?get=forms II. Assurances and Approvals

(Signature of Departmental Executive Officer) (Date) (“Per signature not acceptable)

If this project will not receive external peer review prior to beginning work with animals, the DEO must designate an individual or committee for scientific review and assurance of this ACURF. This person/committee member cannot be involved in this project.

(Signature Certifying Scientific Review and Approval) (Date)

The policies and procedures of the University of Iowa, the AWA and the PHS apply to all activities involving live vertebrate animals performed at or by the personnel of this Institution. Therefore, no activities involving the use of these animals are to be initiated without prior written approval by the University Animal Care and Use Committee (IACUC).

The undersigned is familiar with the AWA and the PHS Policy on Humane Care and Use of Laboratory Animals by Awardee Institutions, the NIH Guide for the Care and Use of Laboratory Animals and the University Guidelines, and agrees to abide by the Principles for the Utilization and Care of Vertebrate Animals Used in Testing, Research, and Training contained in this document. I assure that I will obtain IACUC approval prior to significant changes in the protocol. I assure that students, staff, and faculty on the project are qualified or will be trained to conduct the project in a humane and scientific manner. Any change in the care and use of animals involved in this protocol that would affect their welfare will be promptly forwarded to the IACUC for review. Such changes will not be implemented until the Committee's approval is obtained. Animals will not be transferred between investigators without prior approval.

(Signature of Principal Investigator) (Date) ("Per" Signature not acceptable)

14 (Revised 1 6/11/03) Please download the latest form at http://research.uiowa.edu/animal/?get=forms Approvals

Refer to IACUC Signature Date:

Administrative Approval Duplicate Submission Approved by Full IACUC at Date: convened meeting Signature Date:

Veterinary Review Complete Refer to IACUC Signature of Veterinarian Date:

Approved Refer to IACUC Signature of Designated Reviewer Date:

Comments of University Reviewers:

15 (Revised 1 6/11/03) Please download the latest form at http://research.uiowa.edu/animal/?get=forms INFORMATION AND INSTRUCTIONS FOR THE ANIMAL CARE AND USE REVIEW FORM (ACURF)

Please complete all parts of the attached form. This application must be completed on a word processor, and submission must include a signed hardcopy and computer file (Word or Word Perfect format). E-mail the file to [email protected]. Please return the signed hardcopy to the OAR, 400 Medical Laboratories. The reviewers would also appreciate the formatting of your answers in a manner that allows for ease of review (i.e. boldface). Please note: Six weeks is required to process each application.

University policy and federal law require a review of projects for humane treatment and safe use of vertebrate animals. At the University of Iowa, the review is conducted by the University Institutional Animal Care and Use Committee (IACUC).

Principal investigators and course directors must obtain approval from the IACUC before initiating any research, testing or instructional project involving the use of live vertebrate animals. (The U.S. Public Health Service requires verification of IACUC approval of animal care and use for funded projects before monies will be released for use. For projects funded by non-PHS agencies; verification of IACUC approval of animal care and use generally must occur within 60 days after submission of an application or proposal. Projects with multiple components, such as Program Projects, may require several ACURFs. IACUC approval must also be obtained prior to significant changes in previously approved protocols.

The maximum period of approval is three years. (An annual review of your approved protocol is also required utilizing the Annual Review Form, which will be sent to you 60 days prior to the annual date.) Prior to initial IACUC review, an approval number will be assigned to the project. No project involving the use of vertebrate animals may be initiated without approval by the IACUC, including projects where animals are not directly purchased (e.g. wild trapping, in-house breeding, field observation).

The Office of Animal Resources (OAR) may be contacted for guidance in selecting analgesics, anesthetics, methods for euthanasia, nursing care techniques, etc. The OAR maintains a repository of information on veterinary medicine, laws and standards, and many aspects of the humane care and use of animals. OAR professional and technical staff are available for training and instruction of groups or individuals in animal manipulations. Instructional Material is available on the OAR Home Page: http://research.uiowa.edu/animal Please note that approved and funded (or activated) ACURFs are available for public inspection (Iowa Public Records Act, Chapter 22, Iowa Code). In order to ensure that the information contained in this form is not misinterpreted, it is imperative that significance, aims and procedures of your protocol be in terms which are understandable by the lay public. Your attention to this will greatly facilitate the dissemination of accurate information concerning the essential role of animals in research and teaching. Be assured also that you will be contacted before any information concerning your project is released. It is also advised and encouraged that information supplied to the public and to the news media be made available with the assistance of the Health Science Relations Office 335-8037 or University Relations Office 335-0557.

If you have concerns regarding the security of the animals or the animal facilities, contact OAR at 335-7985 or Department of Public Safety at 335-5027.

16 (Revised 1 6/11/03) Please download the latest form at http://research.uiowa.edu/animal/?get=forms UNIVERSITY OF IOWA PRINCIPLES FOR THE CARE AND USE OF LABORATORY ANIMALS

(Adapted from the U.S. Government Principles for the Utilization and Care of Vertebrate Animals Used in Testing, Research, and Training)

I. The transportation, care and use of animals must be in accordance with the Animal Welfare Act and other applicable federal and state laws, guidelines, and policies.

II. Procedures involving animals should be designed and performed with due consideration of their relevance to human or animal health, the advancement of knowledge, or the good of society.

III. The animals selected for a procedure should be of an appropriate species and quality and the minimum number required to obtain valid results. Alternative methods such as mathematical models, computer simulation, and in vitro biological systems must be considered.

IV. Proper use of animals, including the avoidance or minimization of discomfort, distress, and pain when consistent with sound scientific practices, is imperative. Unless the contrary is established, investigators must consider that procedures that cause pain or distress in human beings may cause pain or distress in other animals.

V. Procedures with animals that may cause more than momentary or slight pain or distress should be performed with appropriate sedation, analgesia, or anesthesia. Surgical or other painful procedures must not be performed on unanesthetized animals paralyzed by chemical agents.

VI. Animals that would otherwise suffer severe or chronic pain or distress that cannot be relieved must be painlessly euthanized at the end of the procedure or, if appropriate, during the procedure. UI veterinarians have the authority to euthanize animals whose welfare is seriously threatened. The action will follow contact or several efforts to contact the responsible investigators.

VII. The living conditions of the animals should be appropriate for their species and contribute to their health and comfort. Normally the housing, feeding, and care of all animals used for biomedical purposes must be directed by a veterinarian or other scientist trained and experienced in the proper care, handling, and use of the species being maintained or studied. In any case, veterinary care shall be provided.

VIII. Investigators and other personnel shall be appropriately qualified and experienced for conducting procedures on living animals. Adequate arrangements shall be made for their in-service training, including the proper and humane care and use of laboratory animals.

IX. Where exceptions are required in relation to the provisions of these Principles, the decisions should not rest with the investigators directly concerned but should be made, with due regard to Principle II, by an appropriate group such as an institutional animal research committee. Such exception should not be made solely for the purpose of teaching or demonstration.

17 (Revised 1 6/11/03) Please download the latest form at http://research.uiowa.edu/animal/?get=forms

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