Abbreviated Animal Component for Use of Non-Living Tissues

#______IACUC USE ONLY San Jose State University Institutional Animal Care and Use Committee

Request for IACUC Approval Exemption

Type and return completed form to University Animal Care at extended zip 0100.

Exemptions for Sponsored Projects/Foundation, complete sections 1, 2, 3 and 5 Exemptions for Academic Projects/Graduate Studies, complete sections 1, 2, 4 and 5

1. SJSU Project Director/PI: Department: Submitter’s name/affiliation: Phone: Email: Project Title:

2. Brief Overview of the Project Scope and Purpose:

3. Include Grant, Contract or Project Reference Number:

4. Include names of all students/individuals who will participate in the project and will be covered by this exemption:

5. Statement of Assurance By signing this application for request of IACUC approval exemption of a project, I verify that: 1) I have read Academic Senate Policy S14-6 and have sufficient understanding of SJSU Animal Welfare Policy requirements to recognize the above project is exempt from IACUC review and oversight; 2) No live animals will be handled by University affiliates for this project; and 3) No University affiliate will benefit from activities or contract work described herein by way of data collection or analysis; academic performance; or in publication.

Submitter’s Signature:______Date:

6. IACUC Approval Exemption Granted:

______IACUC Coordinator Signature Date