IIUM Animal Care & Use Committee (IACUC) Approval Application

APPLICATION FORM
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Notes:
1. Please complete the application form with accurate information. Any application with inaccurate information and incomplete will result in the delay of your application processing.
2. Please take note of your application ID and download link of your submitted form.
3. You will be informed via email for proposal deliberation.
4. For any inquiry kindly contact us via:
Email: iacuc@iium.edu.my or

Br. A'imullah: 09-5704733

*link for PDF Form (for reference only)
Type of Application
Contact Details
Applicant Name*
E-mail*
Department*
Kulliyyah /Faculty*
Institution*
Contact Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Investigator Information
Honorifics 1
Honorifics 2
Principal Investigator Name*
Principal Investigator Email*
Co- investigator(s) name *
Student Name
Name of student involve in this study if any.
Other personnel relevant to the research/project
Describe the role, and expertise where relevant (e.g. counsellor), of these other personnel
Is it intended that other people, not yet known, will play a specified role in the conduct of this research/project?

YesNo
Do the researchers / investigators or others involved in any aspect of this research project require any additional training in order to undertake this research?*

YesNo

Project/Research Information & Experimental Design
Application Category*
Project/Research Title*
Description of the research/project in plain language*
Justify the species and/or strain used for this research purpose. Please provide references for the proposed animal model or disease/condition (e.g. diabetes mellitus, osteoarthritis)*
State the aims of the research/project and the research question and/or hypotheses, where appropriate.*
Sample Size and justification (Please provide sample size calculation)*
Methodology (Please upload the schematic diagram for animal grouping)*
Statistical technique employed*
Indicate how the project will be funded?*

SponsorsResearch Grant
Fund Details
Provide the start and finish dates for the whole of the research/project including data

analysis
Project Start Date*

DayMonthYear
Project End Date*

DayMonthYear
Study Site*

ETHICAL IMPLICATION
Please state the ethical implication of animal use*
Explain rationale for animal use (why non-animal model cannot be use)*
Justify the appropriateness of selected species*
Anticipated impact and potential benefits to human and/or animal welfare*

Declaration & Signature
I hereby declare that I and I or co-workers I co -investigators have the appropriate qualifications and experience to perform the procedures described in this project. I am familiar with the provisions of the "IIUM Animal Ethic Policy" and Malaysian "Animal Welfare Act 2015" for the Care and Use of Animals for Scientific Purposes; and accept responsibility for the conduct of the procedures detailed above; in accordance with the requirements laid down by Institutional Animal Ethics Care and Use Committee (IACUC) IIUM.*

YesNo
I further declare that the procedures described in this project do not constitute unnecessary repetition of work carried out by other teaching activities or previous research workers or myself, and that each person engaged in this project has been adequately instructed in, and is competent to perform, procedures that they are to carry out. If they are not already skilled in the procedures, I will be responsible for seeing that they obtain the necessary training in advance, so that each procedure on an animal will be carried out in the most appropriate manner.*

YesNo
I hereby allow IIUM IACUC to do prompt inspection on the animal facilities that I have listed in this form whenever necessary*

YesNo
NOTICE!

Kindly upload your proposal and other document via https://forms.gle/53sQfzXtbVcdRM5a8. Failure to do so will make your application not processed by IACUC.
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	Frequency	Performed by (name)
Feeding
Changing water bottle/bowl/tank
Changing bedding/litter tray/filter
Changing/cleaning cage/pen/tank/filter

	Yes	No
Ionizing Radiation
Carcinogen/terratogen
Pathogenic Organism
Genetic Modification
Cloning
Others

APPLICATION FORM

Contact Details

Investigator Information

Project/Research Information & Experimental Design

Animal Welfare & Care

Research Animal Information

Animal Husbandry

Procedure to be carried out on animals

SAFETY AND HEALTH ISSUE

ETHICAL IMPLICATION

Declaration & Signature

NOTICE!