復(fù)旦大學(xué)倫理審查申請(qǐng)表 - 復(fù)旦大學(xué)實(shí)驗(yàn)動(dòng)物科學(xué)部

1、復(fù)旦大學(xué)實(shí)驗(yàn)動(dòng)物科學(xué)部動(dòng)物實(shí)驗(yàn)倫理審查申請(qǐng)書(shū)Fudan University Experimental Animal DepartmentApplication for Ethical Approval for Research Involving Animals申請(qǐng)日期：年月日App. Date(YY-MM-DD):申請(qǐng)人姓名Name of Principal Investigator聯(lián)系人姓名Contact Person申請(qǐng)人單位Department聯(lián)系人電話(huà)Contact Tel. No.課題名稱(chēng)Project Title課題性質(zhì)Funding Source & Number實(shí)驗(yàn)

2、動(dòng)物從業(yè)人員上崗參與實(shí)驗(yàn)人員姓名Name職稱(chēng)Title證號(hào)Animal UserPermit No.聯(lián)系電話(huà)Tel.No.Additional ResearchPersonnel實(shí)驗(yàn)概述（包括實(shí)驗(yàn)?zāi)康?，?shí)驗(yàn)設(shè)計(jì)，對(duì)動(dòng)物進(jìn)行的每一步詳細(xì)操作，實(shí)驗(yàn)結(jié)束后動(dòng)物的處理包括安死術(shù)等。）Description of Project (Please describe study objectives and experimental design; specify all proceduresperformed on animals, post procedure animal care, and the

3、fate of animals including euthanasia criteria andmethod.)動(dòng)物來(lái)源 Source使用動(dòng)物情況品種品系 Species or Strains等級(jí) Grade規(guī)格 SpecificationsAnimalRequirements數(shù)量 Quantity 只（ 只； 只）計(jì) 劃 進(jìn) 駐 日 期 （ Proposed Date of 計(jì) 劃 結(jié) 束 日 期 （ Proposed Date ofCommencement）Completion）年月日年月日本人已認(rèn)真審閱此申請(qǐng)表所填內(nèi)容，保證所填內(nèi)容真實(shí)可靠，并將嚴(yán)格遵守上述實(shí)驗(yàn)方申請(qǐng)人承諾Princi

4、palInvestigators案。(I confirm that I will ensure that the requirements for the treatment of the animals asdetailed in this application and as approved by the Animal Ethics Committee will be metduring the course of the project.）Declaration簽名（Signature）日期（Date）年月日1. 該項(xiàng)目的科學(xué)重要性和必要性，期望的科學(xué)獲益。（The significa

5、nces, necessity and theexpected scientific benefits of the proposal work.）2. 所使用的動(dòng)物品種、等級(jí)、規(guī)格是否合適，使用數(shù)量的計(jì)算依據(jù)。（The species, strains,grade, specification and number of the animals to be used should be justified.）3. 能否通過(guò)改良設(shè)計(jì)方案替代或減少使用所用動(dòng)物。(Rational for animal use should bejustified, including the alternati

6、ves to animal use, a refined study design to replace orreduce animal number to be used.)4. 實(shí)驗(yàn)操作中是否善待動(dòng)物，包括合理的實(shí)驗(yàn)終點(diǎn)，麻醉方案，不麻醉的理由及減少相應(yīng)動(dòng)物痛苦的措施，實(shí)驗(yàn)結(jié)束動(dòng)物的處理，動(dòng)物安樂(lè)死方案等。（Appropriate animalcare and handling throughout the experiment, including a scientific sound endpoint;anesthetics, analgesics, sedatives or tran

7、quilizers that are to be used; explanation for anyConsiderationsprocedure cause unrelieved pain or distress; disposition of animals at end of study; andeuthanasia criteria and method.）5. 是否使用對(duì)人體或環(huán)境有害試劑，有潛在感染性試劑，放射性物質(zhì)，是否使用遺傳修飾試劑，是否進(jìn)行遺傳操作，相應(yīng)的防護(hù)措施。（Are the materials to be used harmfulor toxic? Are ther

8、e any radioactive agents, infectious agents, genetic modified agents, andthe genetic manipulation to be used in the experiment? If yes, the safety measures shouldbe specified.）6. 是否使用轉(zhuǎn)基因動(dòng)物，來(lái)源是否符合國(guó)家規(guī)定，是否進(jìn)行免疫隔離。(Are geneticmodified animals to be used in the experiments? IF yes, the source should be va

9、lid and theanimals should be quarantined.)實(shí)驗(yàn)動(dòng)物保護(hù)、福利、倫理小組意見(jiàn)Comments, Provisos or Reservations of Animal Ethics Committee代表簽名：Name of Ethics Committee RepresentativeDate(YY-MM-DD):年月日審查項(xiàng)目Ethical說(shuō)明：（無(wú)需打印）1、 申請(qǐng)人必須為課題負(fù)責(zé)人。2、 申請(qǐng)人單位必須說(shuō)明科室。3、 課題性質(zhì)注明基金資助名稱(chēng)和編號(hào)。4、 必須寫(xiě)明所有實(shí)驗(yàn)參與人員，不在表中人員動(dòng)物部有權(quán)拒絕其進(jìn)入動(dòng)物房。5、 動(dòng)物來(lái)源為外購(gòu)的，如無(wú)特殊