中國(guó)疾病預(yù)防控制中心實(shí)驗(yàn)動(dòng)物福利倫理審查申請(qǐng)表

編號(hào)(Num.)中國(guó)疾病預(yù)防控制中心

實(shí)驗(yàn)動(dòng)物福利倫理審查申請(qǐng)表ChineseCenterforDiseaseControlandPreventionTheApplicationFormForAnimalExperimentalWelfare&EthicalInspection、基本信息(BasicInformation)實(shí)驗(yàn)項(xiàng)目名稱NameofResearchProject項(xiàng)目負(fù)責(zé)人姓名NameofApplicant職稱/職務(wù)Professionaltitle電話/傳真Telephone/FAX電子郵件E-mail單位名稱NameofInstitute動(dòng)物實(shí)驗(yàn)設(shè)施名稱NameofAnimalfacility許可證編號(hào)No.ofLicense動(dòng)物實(shí)驗(yàn)設(shè)施地點(diǎn)AddressofAnimalFacility實(shí)驗(yàn)周期ExperimentalPeriodsFrom:mmddyyyyTOmmddyyyy、直接進(jìn)行動(dòng)物實(shí)3僉的人員資料(InformationofPersonnelresponsibleforanimalcare&use)姓名Name性別Gender職稱/職務(wù)Professionaltitle崗位證書編號(hào)No.ofCertification動(dòng)物實(shí)驗(yàn)經(jīng)驗(yàn)ExperienceofAnimalExperiment□有Experienced□需要帶教UnderthesupervisionofotherExperiencedpersonnel□有Experienced□需要帶教UnderthesupervisionofotherExperiencedpersonnel□有Experienced□需要帶教UnderthesupervisionofotherExperiencedpersonnel、實(shí)驗(yàn)動(dòng)物信息(LaboratoryAnimalsInformation)動(dòng)物品種/品系A(chǔ)nimalSpecies年齡/體重Age/Weight數(shù)量(Quantity)供應(yīng)單位Suppliers1.2.3.四、動(dòng)物飼養(yǎng)(AnimalBreeding)由動(dòng)物中心專人負(fù)責(zé)(Chargingbyspecialpersonintheanimalcenter);由實(shí)驗(yàn)室人員負(fù)責(zé)，負(fù)責(zé)人姓名(Chargingbylabstaff,nameofprinciple)五、簡(jiǎn)述下歹U實(shí)驗(yàn)步驟(Describethefollowingexperimentstepinbrief):(1)使用麻醉藥品名稱及麻醉方式(NameandMethodsofAnaesthesia)：注：使用超過一種實(shí)驗(yàn)動(dòng)物時(shí)，須分別填報(bào)每種動(dòng)物所使用之藥品劑量(Intheoccasionthatmorethanonesortofanimalisneeded,Pleasefillouttheleechdomdosagethateachsortanimalisused.)。無須麻醉原因(ThereasonofnoAnaesthesia):(2)若動(dòng)物需長(zhǎng)時(shí)間保定超過四小時(shí)，請(qǐng)說明所用器械與方法(Ifanimalshouldbeimplementedrestraintformorethan4hours,PleasedescribetheMethodsofrestraint):六、請(qǐng)說明實(shí)驗(yàn)結(jié)束后動(dòng)物的處置方式(Pleaseexplainthedisposalmethodsofanimalafterexperiment):(1)實(shí)驗(yàn)后動(dòng)物疼痛處理及照顧辦法(Thetendancemethodsforanimalafterexperiment)：(2)安樂死的方法(Methodsofeuthanasia):(3)尸體處理辦法(Disposalofcarcase)：□委托動(dòng)物中心處理(Consignittoanimalcenter)口其它：(Others)本人保證以上所填數(shù)據(jù)完全屬實(shí)(Iassurethattheabovedataistrue.)項(xiàng)目負(fù)責(zé)人簽字(SignatureofApplicant)：?jiǎn)挝簧w章(SealofInstitution)：填報(bào)日期(Date)月(MM)日(DD)年(YYYY)審查結(jié)果(ResultofInspection)通過Approve修正通過ApproveintermsofModification修正意見：opinions不通過Disapprove建議事項(xiàng)：suggestions中國(guó)疾病預(yù)防控制中心實(shí)驗(yàn)動(dòng)物福利倫理審查委員會(huì)LaboratoryAni