ࡱ> _a^ Jbjbj =XP>;;8k,+,8$ DX n+p+p+p+p+p+p+-k0p+ud"$ddp+;;3+dL;8n+dn+rj(TsF)FՇv|(Z++0+,(z%1,%1F)F)%1V)dddddddp+p+ddd+,dddd%1ddddddddd : San Jose State University Institutional Animal Care and Use Committee Request to Accept Alternate IACUC Approval Fill out form completely. Type and return to 91 University Animal Care at extended zip 0100. If a line item is not present or hold true, mark None. If a line item does not pertain, mark N/A A valid IACUC approval letter from the approving institution is required to accompany this form. Check here  FORMCHECKBOX  if there was no IACUC oversight of the activity described herein. 1. SJSU Submission Information: Date:  FORMTEXT       Select One: Use of previously collected data  FORMCHECKBOX  Approval of an ongoing activity/collaboration  FORMCHECKBOX  SJSU Faculty/advisor:  FORMTEXT       Co-Investigator:  FORMTEXT       Co-investigator Email and Phone:  FORMTEXT       Project Title:  FORMTEXT       Project Approval Period (3-year maximum):  FORMTEXT       through  FORMTEXT       2. Study Information: Summary of project aims and purpose:  FORMTEXT       Study location/localities:  FORMTEXT       Collaborator s Name:  FORMTEXT       Collaborator s email:  FORMTEXT       Indicate study period for use of previously collected data:  FORMTEXT       through  FORMTEXT       N/A  FORMCHECKBOX  List all Scientific Collection Permits and Permit Holders for this study:  FORMTEXT       List all study animals and approximate numbers of each species covered by this submission:  FORMTEXT       Refer to attached species list if checked  FORMCHECKBOX  3. Performance Site Information: Attach IACUC Approval Letter from Performance Site Institution Name and Address:  FORMTEXT       IACUC Administration Contact Information:  FORMTEXT       USDA Registration #:  FORMTEXT       OLAW Assurance #:  FORMTEXT       AAALAC Accredited Unit #:  FORMTEXT       Name of PI at Performance Site:  FORMTEXT       IACUC Reference #  FORMTEXT       Protocol Title at Performance Site:  FORMTEXT       4. Project Funding Source and Award/Contract #:  FORMTEXT       5. Personnel: List all SJSU personnel and their affiliation to be covered by this submission:  FORMTEXT       6. Assurance Statement By signing below: I verify that the information described herein isGHIQcstu       5 6 7 : ; < = > û˭yyyyn`h7G"hDB5CJ\aJhLShDBCJaJh+h6 hg6 hm?6 hr6 h6hCJaJhoCJaJhiHCJaJh9ho5CJ \aJ hW CJaJh9CJaJhoCJaJhoCJaJh+hoCJaJhoCJ$aJ$"jh CJUaJmHnHu!GHItu< = >  vv)dh$d%d&d'dNOPQgd7G"&$d%d&d'dNOPQgdDBL]LgdDBdhgd $dha$gd+dhgd+$a$ $&dPa$ >       , F J ̽Ꙏ{rir]{UIU:jvh'CJUaJjh'CJUaJh'CJaJh;hL>5C<'5CJaJhL>5CJaJhL>CJaJhL>5CJ\aJhQ+hDBCJaJh9hDB5CJ \aJ +jh Ph7G"CJOJQJU^Jh Ph7G"CJOJQJ^J%jh Ph7G"CJOJQJU^Jh7G"5CJ\aJh95CJ\aJhDB5CJ\aJ  T 4h<6B,B Ldh]LgdiH d]gdr dh]gd'dhgd!dgdL>dhgdL> Ldh]Lgd'dhgdiHL]LgdDB   0 2 4 6 < ˿sdULAh<'5CJ\aJh<'CJ\aJh95CJOJQJ\^Jh<'5CJOJQJ\^J+jh Ph9CJOJQJU^Jh Ph9CJOJQJ^J%jh Ph9CJOJQJU^Jh95CJ\aJh9CJ\aJh Ph9CJ\aJh Ph9>*CJ\aJhL>CJaJ"jh'CJUaJmHnHujh'CJUaJ      N P d f h ﾯxixWxK䴳ԱL>䴳L>䴳L>䴳<'CJaJh'CJaJhxCJaJh95CJ\aJh95CJOJQJ\^Jh<'5CJOJQJ\^J+jVhFh9CJOJQJU^Jh9CJOJQJ^Jjh9CJOJQJU^Jh r t  , . 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I certify that all SJSU personnel who are participating in an ongoing activity at an outside performance site: 1) have been adequately trained in policies related to the care and use of laboratory animals at that institution; 2) have been informed of and have met all occupational health requirements imposed at that institution; and 3) are familiar with and will abide by all IACUC requirements related to the care and use of live animals stated in the approved protocol at that institution. I understand that in order to maintain SJSU IACUC approval of this application: a) IACUC approval for animal care and use by the performance site must be/remain valid and consistent with this description; b) SJSU approval will not exceed the IACUC approval period specified by the performance site for ongoing activities/collaborations without receipt of written verification of IACUC approval renewal; and c) that I must promptly advise the SJSU IACUC of any future changes, provisions or suspensions imposed by the performance site s IACUC as it relates to the activity described herein. SJSU Faculty/Advisor s Signature:________________________________ Date:  FORMTEXT       7. 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