Johns Hopkins University Animal Care and Use Committee

Johns Hopkins University Animal Care and Use Committee **Below for ACUC Use**

Principal Investigator Departure Notification Date Received: Expiration Date:

Protocol Number:  Logged  Database Protocol Title: Principal Investigator: School: Department: Building: Room Number: Campus: Office Phone: Fax: E-mail:

1. What is your scheduled departure date?

Do you intend for this protocol to remain active after your departure? Yes No

If yes, please provide contact information for yourself for after you leave.

Who can we use as a local contact?

2. Please indicate if you currently have animals housed at JHU under this protocol. Yes No

3. If you have animals on this protocol, where are they currently housed?

4. If you currently have animals, do you expect any to remain at JHU after your departure? Yes No If yes, please indicate who will be the local contact for these animals (must be someone who is currently approved to work on this protocol; or submit a personnel amendment).

Name: Phone: E-mail:

5. Will this protocol be transferred to a different PI at JHU? Yes No If so, please fill out a change in PI amendment request form

PI Signature: ______Date: ______

Please return a signed copy to the ACUC Office, Reed Hall, room B122 or fax this to 443-287-3747.

Revised 4/08