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Incomplete application will result in the return of the application and delay in the granting of the approval. Attach a copy of the proposal (research / elective / teaching / other). Application must be word-processed or typewritten and forwarded to: Chairperson, Animal Ethics Committee (AEC), Centre for Research & Innovation, Universiti Malaysia Sabah (UMS), Jalan UMS, 88400 Kota Kinabalu, Sabah. Please submit the application and direct all enquiries to the following address: Secretary, Animal Ethics Committee, Centre for Research & Innovation, Universiti Malaysia Sabah (UMS), Jalan UMS, 88400 Kota Kinabalu, Sabah. Tel: (6)088-320 393; Fax: (6)088-320 127 Email: ric@ums.edu.my TYPE OF APPLICATION: [ Please tick ( / ) ] RESEARCH ( ) / ELECTIVE ( ) / TEACHING ( ) / OTHER ( ) please specify: _____________________ If teaching / elective project, state course name and code: ____________________________________________________ NAME OF PRINCIPAL INVESTIGATOR / CO-ORDINATOR / CHAIRPERSON: ____________________________________________________ FACULTY / CENTRE: ____________________________________________________ PROJECT TITLE: ____________________________________________________  SHAPE  Received by Secretary, Animal Ethics Committee AEC File No: Date:  SHAPE  1. PROPOSAL  1.1 Project Title: 1.2 Project Objectives: 1.3 Summary of the Project/ Abstract (not more than 250 words): 1.4 State the Ethical Implications of the Project: i. ii. iii. 1.5 Duration Proposed commencement date : Estimated duration from : dd/mm/yyyy to: dd/mm/yyyy 1.6 Investigators / Co-ordinators / Chairperson: Please list the names of persons responsible in handling animals (including students): No. Name Dept/ School Investigators / Co-ordinators / Chairperson I/C / Passport No. Contact No. Signature & Date 1.       2.       3.       4.       5.       6.        2. CLASSIFICATION OF PROJECT ( Please circle one or more )  Project requiring animals to be sacrificed for the preparation of the whole animals or tissue specimens. Procedure carried out under anaesthesia and the animals sacrificed without regaining consciousness. Survival after an intervention, which causes minimal stress of short duration (e.g. venepuncture, brief restraint, and blood vessel cannulation under anaesthesia). Survival after an intervention, which causes major or prolonged stress (e.g. major surgery, prolonged restraint, administration of toxic or painful substances and major behavioural modification). E. Purely breeding projects. Production of antisera. Teaching purposes. Fieldwork Other procedures  please specify: ____________________________________________________ 3. ANIMALS REQUIRED  3.1 TABLE OF PROPOSED ANIMAL USAGE: (NOTE: Ethical Clearance can only be given for work involving LIVE VERTEBRATES for a maximum period of three calendar years only.) No. Scientific and Common Name Male (No.) Female (No.) Non- Specific Gender (No.) Total (No.) 1.      2.      3.       Grand Total      3.2 SOURCES OF ANIMALS: (Address of Source / Supplier :) 3.3 LOCATION OF ANIMALS: (Please indicate where the animals will be housed during the experimental period) 3.4 ENVIRONMENTAL ENRICHMENT: (Please indicate type(s) of environmental enrichment (special / specific) to be used) 3.5 CARE OF ANIMALS: (State the name and contact address of the persons responsible for the daily care of animals (including after office hours, weekends and public holidays)) 3.6 PERMITS REQUIRED: (If protected native species, provide details of appropriate permits held) Holder : Issuing Agency : Date of Issue : Serial No. : Period of Validity : 3.7 JUSTIFICATION: (Please explain the basis for selection of the species and justification for the number of animals to be used.) NOTE: Minimum number of animals to be used to achieve the objectives of the project. 4. EXPERIMENTAL METHODS  4.1 Procedures to be carried out on the animals: (Please circle) Surgery: YES / NO (If YES, answer 4.2 and 4.3) Anaesthesia: YES / NO (If YES, answer 4.4 and 4.5) Other: YES / NO (If YES, answer 4.6 and 4.7) State surgical procedures to be carried out on the animals: Name the person(s) having experience in performing the procedures: Anaesthetic to be used: Name : Dose : Route of Administration : Duration : Clinical signs to ensure anaesthesia are adequate: Neuromuscular Blocking Agent to be used: YES / NO If YES, Agent: Dose: Route of Administration: Duration: Justification for use of neuromuscular blocking agent: Outline the procedure: Name the person(s) having experience in performing the procedure: Supervision during experimentation: (Detail the extent and method of supervision of animals during experimentation, including methods to be used for assessing and preventing pain and distress). Post-procedural care: (Detailed arrangements made by the investigators for immediate and continuing post-operative and / or post-procedural care, including details of restraint, housing and analgesics to be used). Post-procedural survival time for the animals: (hours / days / months / years) 5. COMPLETION OF PROJECT  5.1  Animals to be euthanized: YES / NO If YES, state the method to be used: name of the person performing euthanasia: method of disposal of euthanized animals: If animals are not euthanized, state what happen to them: 6. HAZARDOUS MATERIALS  Does the project involved exposure of live animals to any of the following: 6.1 Ionising Radiation: YES / NO  If YES, Agent:  6.2 Carcinogen / Teratogen: YES / NO    If YES, Agent:  6.3 Pathogenic Organisms: If YES, Agent: YES / NO  6.4 Other: Please give details. YES / NO  If YES to any above; Please indicate the health risks to human and / or animals involved in the project: 7. GENETIC MATERIALS  7.1 Will you be isolating the DNA? YES / NO  7.2 Will you be inserting DNA into live animals? YES / NO 8. DECLARATION BY PRINCIPAL INVESTIGATOR / COORDINATOR / CHAIRPERSON:  I hereby declare that I and / or co-investigators / co-coordinators / vice chairperson have the appropriate qualifications and experience to perform the procedures described in this project. I am familiar with the provisions of the UMS rules and regulation in animals for the Care and Use of Animals for Scientific Purposes; and accept responsibility for the conduct of the experimental procedures detailed above; in accordance with the requirement of the rules and regulation laid down by Animal Ethics Committee UMS. I further declare that the procedures described in this project do not constitute unnecessary repetition of work previously carried out by other 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. _____________________ _____________ Signature: Principal Investigator Date Assesment and Certification for Approval of a Research Project Involving the Use of Animals, and Approval as an Investigator for the Project Name of Applicant : F/P/I/U : Title of Project : AEC File No : *** For secretariat use only. 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