Exemption from Scientific and Regulatory Standards - Request Form

EXEMPTION FROM SCIENTIFIC AND REGULATORY STANDARDS - REQUEST FORM

Principal Investigator: Instructions: Complete all sections of this form (indicate any sections that do not apply with “N/A”) and submit Protocol Title/s: completed materials to the address below or with original protocol. Please Type or Print. Protocol Number/s:

OfficeDepartment: of Regulatory Affairs Phone: 215.898.2615 Institutional Animal Care and Use Submit Completed Fax: 215.573.9438 CommitteeMailing Address: (IACUC) Application to: E-Mail: [email protected]. 133 S. 36th St. , Mezzanine Level Philadelphia, PA 19104-3246 Phone:

E-Mail:

STATEMENT OF AGREEMENT:

I have acquainted myself with the Federal Regulations and University Policies regarding the care and use of vertebrate animals in testing, research and education activities. I am requesting an IACUC exemption for the following standards or guidelines. If the exemption is granted, I am aware that this exemption may be reported to the USDA and or OLAW as required by law.

P.I. Signature: Date:

Species and Number of Animals: Give an estimate of the number of animals covered by this exemption.

Facility, Building and Room Number where the exemption will take place:

Exemption: Please food/water deprivation or restriction check from which the exercise plan for dogs standard or guide you the environmental enrichment plan for nonhuman primates wish to have an use of an animal in more than one major survival surgery exemption. maintaining animals at temperatures or humidities outside the ranges specified by the standards cleaning or sanitation requirements diurnal light cycle requirement space requirement (including innovative enclosures and metabolic cages) Other: e.g. (Federal, State, UPenn Animal Guidelines, etc.): Justification for the Exemption: Explain why you need to deviate from the standards and describe the duration of the exemption, i.e. weeks, year, permanent, etc. Distress: How is this Please explain your plans to relieve stress associated with the deviation from standard. exemption expected to increase stress in the animal?

FOR IACUC USE ONLY Date of Exemption : Expiration Date of Exemption: IACUC Signature: