ࡱ > F H E # bjbj =( P W ; ; 8 , $ * f ' 4 j D $ W) Y) Y) Y) Y) Y) Y) $ n+ . }) E " 4 }) ; ; 3 ) L ; 8 W) W) r ?' T s ( `p~ X ' C) ) 0 * ' z . U . ( ( . +( " ( @ T ] }) }) * . : 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. 91 Project Director/PI: FORMTEXT D e p a r t m e n t : F O R M T E X T
S u b m i t t e r s n a m e / a f f i l i a t i o n : F O R M T E X T P h o n e : F O R M T E X T E m a i l : F O R M T E X T
P r o j e c t T i t l e : F O R M T E X T
2 . B r i e f O v e r v i e w o f t h e P r o j e c t S c o p e a n d P u r p o s e :
F O R M T E X T
3 . I n c l u d e G r a n t , C o n t r a c t o r P r o j e c t R e f e r e n c e N u m b e r : F O R M T E X T
4 . I n c l u d e n a m e s o f a l l s t u d e n t s / i n d i v i d u a l s w h o w i l l p a r t i c i p a t e i n t h e p r o j e c t a n d w i l l b e c o v e r e d b y t h i s e x e m p t i o n :
F O R M T E X T
5 . S t a t e m e n t o f 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 91 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 G I n o 0 A b c d e g i k p ǹzrzj[P hz^ ho CJ aJ j hz^ ho CJ UaJ hP( CJ aJ h;0p CJ aJ h|x CJ aJ ho 5CJ \aJ ho CJ aJ ho 5CJ \aJ h,y 5CJ \aJ hIz ho 5CJ \aJ h0"D ho 5CJ \aJ ho CJ aJ ho 5\ ho CJ aJ ho CJ aJ ho CJ$ aJ$ "j hAI CJ UaJ mH nH u G H I n o c g & $d %d &d 'd N O P Q gdIz ) dh $d %d &d 'd N O P Q gdIz & $d %d &d 'd N O P Q gd0"D $a$ gdIz $ a$
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S u b m i t t e r s S i g n a t u r e : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ D a t e : F O R M T E X T
6 . I A C U C A p p r o v a l E x e m p t i o n G r a n t e d :
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ___________________
IACUC Coordinator Signature Date
#_________________________
IACUC USE ONLY
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