The University of Texas Rio Grande Valley Institutional Animal Care and Use Committee Continuing Review Request Form Every research project approved by the Institutional Animal Care and Use Committee must be reviewed annually. In order to assist the review, the Principal Investigator or Project Manager must report in writing the status of the Project each year.

Projects not having major changes as indicated by the questions below, will be continued another year without submitting a formal “Application to Use Animal Subjects in Research and/or Teaching,” IACUC Form 1 - Application.

Protocol Number: Date of Request: Principal Investigator: Last Name: Click here to enter text. First Name: Click here to enter text.

Department: Click here to enter text. College: Click here to enter text.

Institution, if other than UTRGV: Click here to enter text.

Title of Project: Click here to enter text.

Protocol Approval History Indicate the date of the original IACUC approval and the date and type of any subsequent approvals Date Action ☐ ORIGINAL IACUC APPROVAL ☐ Annual Review ☐ Modification ☐ Triennial Review ☐ Annual Review ☐ Modification ☐ Triennial Review ☐ Annual Review ☐ Modification ☐ Triennial Review ☐ Annual Review ☐ Modification ☐ Triennial Review ☐ Annual Review ☐ Modification ☐ Triennial Review ☐ Annual Review ☐ Modification ☐ Triennial Review ☐ Annual Review ☐ Modification ☐ Triennial Review ☐ Annual Review ☐ Modification ☐ Triennial Review

Significant changes to a protocol after it has been approved require further review by the IACUC. Any changes defined as significant in the following areas will warrant submission of a complete application and a full-review by the IACUC:

I. Have there been ANY CHANGES to: Please check Yes or No: Yes No 1. The objectives of the study? ☐ ☐ If yes, describe in detail on a separate page. 2. Non-survival or survival surgery? ☐ ☐ If yes, describe in detail on a separate page. 3. The invasiveness of a procedure or discomfort to an animal? ☐ ☐ If yes, describe in detail on a separate page. 4. The species used, or in approximate number of animals used? ☐ ☐ If yes, describe in detail on a separate page. 5. The anesthetic agent(s) or withholding of analgesics? ☐ ☐ If yes, describe in detail on a separate page. 6. The method of euthanasia? ☐ ☐ If yes, describe in detail on a separate page.

IACUC Form 2 - Continuing Review Page 1 of 2 Revised: 9/22/15 II. Animals Used: Click here to enter text. Species Total Approved Number Used (as of the date of this request) Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text.

III.List any significant findings in the literature, other sources, or resulting from this study that may affect the design of this study in the future: (Indicate possible changes in the future; if none, indicate none below) Click here to enter text.

IV. List all personnel changes associated with the approved protocol/study: A. Personnel New to Protocol: (For new personnel, attach evidence of completion of required training.) Name Title Role (faculty, staff, or student) Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text.

B. Personnel Left/leaving Protocol: Name Title Role (faculty, staff, or student) Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text.

V. Attach a summary or abstract of your approved protocol.

VI. Signature of the Principal Investigator/Project Manager: (Please submit signed form to [email protected])

Date: Printed Name: Click here to enter text.

VII. IACUC Committee Review (Completed by the Chair of the Committee following IACUC review):

The IACUC has reviewed this Request for Continuance of the study on (date) and, GRANTS continuance; ☐ With no modifications/conditions. ☐ With the following modifications or conditions: Click here to enter text. Click here to enter text. Click here to enter text. ☐ A New IACUC Form-1 “Application to use animal subjects in research and/or teaching” MUST be submitted for the following reasons: Click here to enter text. Click here to enter text. Click here to enter text.

IACUC Form 2 - Continuing Review Page 2 of 2 Revised: 9/22/15 Signed: ______Date: Printed Name: Dr. Masoud Zarei, Chair, IACUC

IACUC Form 2 - Continuing Review Page 2 of 2 Revised: 9/22/15