实验动物伦理审查表ApplicationFormatforEthicalApprovalforResearchInvolvingAnimals申请日期：年月日受理编号:批准文号：YMD.IACUCIssueNo.课题名称及编号：ProgramandNo.课题来源：sponsor课题负责人：NameofPrincipalInvestigator所属中心：Department动物实验负责人：ContactPerson电话和信箱：Contact.andEmail课题实施动物实验的人数：NumberofImplement经专业培训的人数：Numberofcertificate参与动物实验操作人员姓名、相关专业证书编号，经验、培训、资格和能力的描述Nameandcertificatenumber，Descriptionofexperience/training/competencyoftheindividualscarryingouttheresearch.动物实验设施许可证编号：Nameandcertificatenumberofthefacility特殊实验设施许可证编号：Nameandcertificatenumberofthefacility现有动物实验设施条件是否与拟开展动物实验的规范性要求相匹配的描述Conformityoffacilityconditionandproposedtocarryoutexperimentrequirement拟实验时间：年月日至年月日Experimentalperiod:YMDtoYMD动物实验项目的目的、必要性、意义和如何设计以达成研究目标的Experimentalobjective,necessityandsignificanceandhowtheprogramhasbeendesignedtoachievetheobjectivesoftheresearch.Animal动物来源：Animalorigin许可证编号：Certificatenumber质量合格证□有Certificationoffitness□无品种/品系.tobe/usedbreed/strain□大鼠rat□小鼠mice□裸鼠nudemice□兔rabbit□犬dog□灵长类primaryanimal等级□普通Grade□CV□清洁□CL□SPF□GF□其他□转基因动物geneticallymodifiedanimal□其它（具体说明）others数量只（早；0）体重gNumber（早；0）Weightg周龄周AgeWeeks选择实验动物种类和数量的原因Reasonsforthechoiceofspeciesandnumbersofanimalstobeused.拟开展动物实验的详细信at详细列出对动物可能造成的所有可预期的伤害，包括动物运输、母个实验方案动物饲养方式、实验操作步骤中等可能产生伤害或不适的细节以及拟采取的防控措施Descriptionoftheoverallharmsexpectedtobeexperiencedbytheanimals—includingdetailsofthelikelyadverseeffectsofeachprotocol,cagebreedingandthestepswhichwillbetakentocontroltheseadverseeffects.iledinformationoftheexperimentsonanimals主要观察指标Mainobservationtarget仁慈终点或实验终结的指标Humaneendpointorexperimentalterminativeindicator动物处死方式Deathconduct非处死动物的处置方式Notforthedeathoftheanimaldisposition□继续使用□Continuetouse□保存的机构□Saveintheagency□放生野外□Releasetothewild□其他，详细说明□Others,detaileddescription动物替代、减少动物用量、降低动物痛苦伤害的主要措施Majormeasurefor3Rs是否使用有毒(害)物质(感染、放射、化学毒、其他)Poisonous(harmful)material(infection,radiate,chemicalpoisonandother)beingused□否no□是yes说明：Declare利害分析的小结，说明为何预期的利益多于害处？Asummaryoftheharm-benefitanalysis-whytheexpectedbenefitsmightbeconsideredtooutweighthepredictedharms?相关的补充说明或辅助证明文件Supplementaryinstructionoranyauxiliarydocumentsforinvestigate信息公开和保密要求：说明那些信息需要保密，那些信息可以公开Declarationfortheinformationdisclosureandconfidentialityrequirements,declaringtheinformationneedtobekeptsecret,theinformationcanbedisclosed.对伦理审查委员有无回避要求Claimingjurorsforbeingdebarb.声明：1、我将自觉遵守实验动物福利伦理相关法规和各项规定，同意接受伦理委员会和实验动物室管理者的监督与检查。2、本人保证本申请表中所填内容真实、详尽和易懂。Declaration:l.Iwillabidebythelawandregulationstipulation,andacceptthesupervisionandinspectionbythecommitteeandlaboratoryanimaldepartment.2.TheinformationIhavegivenisaccurate,detailedandcomprehensive.声明人：课题负责人签(章)Declarant:Signature(stamp)ofPI动物实验负责人签(章)Signature(stamp)ofDirectorofanimalexperiment年月日YMD申报单位意见OpinionofapplicantDepartmentofinstitution研究组负责人签(章)：Signature(stamp)ofthePrincipalInvestigator年月日YMD主管医师意见OpinionofVeterinaryofinstitution主管医师签(章)：Signature(stamp)Veterinary年月日YMD实验动物设施意见Opinionfromlaboratoryanimalfacility设施负责人签(章)：Signature(stamp)ofthefacilityDirector年月日YMD福利伦理委员会审批意见ApprovalopinionofCommittee审查委员表决Inspectionbymembers：Agree();Disagree()主任委员签(章)：Signature(stamp)ofChairmanofCommittee年月日YMD备注：口初审；口第次审查Remarks□firsttrial；□reexamineNo.申报说明：申报时，请提交本表一式两份及电子版。受理文号和审查文号由审查委员会填写。Notice:SubmittingtheApplicationFormatinduplicateandanelectronicedition.The.andIACUCIssueNo.aremakeoutbyJury.
