南京醫(yī)科大學(xué)試驗(yàn)動(dòng)物福利倫理審查申請表

1、南京醫(yī)科大學(xué)實(shí)驗(yàn)動(dòng)物福利倫理審查申請表受理編號(hào)（由受理部門填寫）：科室科室電話申請日期課題負(fù)責(zé)人實(shí)驗(yàn)人實(shí)驗(yàn)人手機(jī)課題小組E-mail課題名稱：經(jīng)費(fèi)來源：參與動(dòng)物實(shí)驗(yàn)人員上崗證書編號(hào)：姓名職稱上崗證號(hào)碼和有效期聯(lián)系電話擬實(shí)驗(yàn)完成時(shí)間：年月日至年月日實(shí)驗(yàn)?zāi)康暮蛢?nèi)容概述（特點(diǎn)及意義）：主要參考文獻(xiàn):3、本項(xiàng)目是否與已通過審查的項(xiàng)目相關(guān)聯(lián)（重復(fù)或類同）？ 如果有，具體的項(xiàng)目名稱與受理號(hào)并附加說明：維通維通利華 上海斯萊克.南京大學(xué)模式所其它（具體說明）質(zhì)量合格證口有無品種/品系大鼠小鼠裸鼠其它（具體說明）等級(jí)口清潔 SPF無菌數(shù)量只（早；）體重體重月齡Mg地點(diǎn)南京醫(yī)科大學(xué)實(shí)驗(yàn)動(dòng)物中心其它（請?zhí)顚懶Ｍ鈱?shí)

2、驗(yàn)動(dòng)物設(shè)施使用證明）設(shè)施口 屏障設(shè)施 普通設(shè)施擬 用 飼主要實(shí)驗(yàn)操作:主要觀察指標(biāo):實(shí)驗(yàn)終結(jié)標(biāo)準(zhǔn)：實(shí)驗(yàn)動(dòng)物死亡處理：減少動(dòng)物痛苦傷害措施：是否使用有毒（害）物質(zhì)（感染、放射、化學(xué)毒、其他）否是說明：如對倫理審查有特殊要求，請說明（例如需要某一委員回避等）:聲明：我將自覺遵守實(shí)驗(yàn)動(dòng)物福利倫理原則，同意接受委員會(huì)或?qū)嶒?yàn)室管理者的監(jiān)督與檢查。聲明人（項(xiàng)目負(fù)責(zé)人和執(zhí)行人）簽字（章）年月日南京醫(yī)科大學(xué)實(shí)驗(yàn)動(dòng)物倫理委員會(huì)審議結(jié)果簽字（章）年月日備注Nanjing Medical University Experimental Animal DepartmentApplication for Ethical

3、 Approval for Research Involving AnimalsNo:App. Date(YY-MM-DD):Name of Principal InvestigatorContact PersonDepartmentContact Tel. No.Project TitleFunding Source &NumberAdditionalResearchPersonnelNameTitleAnimal User Permit No.Tel.No.Description of Project (Please describe study objectives and experi

4、mental design; specify all procedures performed on animals, post procedure animal care, and the fate of animals including euthanasia criteria and method.)AnimalRequirementsAnimal SourceSpecies or StrainsGradeSpecificationsProposed Date of CommencementProposed Date of Completion（早金)QuantityPrincipalI

5、nvestigatorDeclarationI confirm that I will ensure that the requirements for the treatment of the animals as sdetailed in this application and as approved by the Animal Ethics Committee will be met during the course of the project.Signature:Date(YY-MM-DD):The significances, necessity and the expecte

6、d scientific benefits of the proposal work.The species, strains, grade, specification and number of the animals to be used should be justified.Rational for animal use should be justified, including the alternatives to animal use, a refined study design to replace or reduce animal number to be used.。

7、(Appropriate animal care and handling throughout the experiment, including a scientific sound endpoint; anesthetics, analgesics, sedatives or tranquilizers that are to be used; explanation for any procedure cause unrelieved pain or distress;審查項(xiàng)目disposition of animals at end of study; and euthanasia

8、criteria and method.5. Are the materials to be used harmful or toxic? Are there any radioactive agents,EthicalConsiderationsinfectious agents, genetic modified agents, and the genetic manipulation to be used in the experiment? If yes, the safety measures should be specified.6. Are genetic modified animals to be used in the experiments? IF yes, the source should be valid and the animals should be quarantined.說明：（本頁無需打?。?、申請人必須為課題負(fù)責(zé)人；申請人單位必須說明科室。2、課題性質(zhì)注明基金資助名稱和編號(hào)。3、凡項(xiàng)目資金來源不確定、項(xiàng)目執(zhí)行人無實(shí)驗(yàn)動(dòng)物上崗證（需在有 效期內(nèi)）的課題原則上不能進(jìn)行，亦不做倫理審查。4、必須寫明所有實(shí)驗(yàn)參與人員，并與動(dòng)物