<p> #______IACUC USE ONLY San Jose State University Institutional Animal Care and Use Committee</p><p>Request for IACUC Approval Exemption</p><p>Type and return completed form to University Animal Care at extended zip 0100. </p><p>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</p><p>1. SJSU Project Director/PI: Department: Submitter’s name/affiliation: Phone: Email: Project Title: </p><p>2. Brief Overview of the Project Scope and Purpose: </p><p>3. Include Grant, Contract or Project Reference Number: </p><p>4. Include names of all students/individuals who will participate in the project and will be covered by this exemption:</p><p>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. </p><p>Submitter’s Signature:______Date: </p><p>6. IACUC Approval Exemption Granted: </p><p>______IACUC Coordinator Signature Date</p>