實(shí)驗(yàn)動(dòng)物福利倫理審查表ApplicationFormatforEthicalApprovalforResearchInvolvingAnimals受理號(hào)（Appl.No.）：擬申報(bào)的課題名稱：或課題名稱及編號(hào)：ProgramandNo.擬申報(bào)的課題來(lái)源：或課題來(lái)源：Sponsor課題負(fù)責(zé)人NameofPrincipalInvestigator科室Department動(dòng)物實(shí)驗(yàn)負(fù)責(zé)人ContactPerson電話和信箱ContactTel.No.andEmail課題實(shí)施動(dòng)物實(shí)驗(yàn)的人數(shù)NumberofImplement經(jīng)專業(yè)培訓(xùn)的人數(shù)Numberofcertificate參與動(dòng)物實(shí)驗(yàn)操作人員姓名、相關(guān)專業(yè)證書編號(hào)，培訓(xùn)、資質(zhì)、經(jīng)驗(yàn)和能力的描述Nameandcertificatenumber,Descriptionofexperience/training/competencyoftheindividualscarryingouttheresearch動(dòng)物實(shí)驗(yàn)設(shè)施許可證編號(hào)Nameandcertificatenumberofthefacility參考信息：實(shí)驗(yàn)動(dòng)物使用許可：（實(shí)驗(yàn)區(qū)）SYXK(滬)2020-0019實(shí)驗(yàn)動(dòng)物生產(chǎn)許可：（保種繁育區(qū)）SCXK(滬)2020-0002特殊實(shí)驗(yàn)設(shè)施許可證編號(hào)Nameandcertificatenumberofthefacility參考信息：動(dòng)物部P2備案憑證：金字第022015002號(hào)P3資質(zhì)：請(qǐng)咨詢P3實(shí)驗(yàn)室現(xiàn)有動(dòng)物實(shí)驗(yàn)設(shè)施條件是否與擬開展動(dòng)物實(shí)驗(yàn)的規(guī)范性要求相匹配的描述Conformityoffacilityconditionandproposedtocarryoutexperimentrequirement參考（根據(jù)實(shí)驗(yàn)內(nèi)容選擇以下的描述）：SPF級(jí)實(shí)驗(yàn)該設(shè)施經(jīng)過(guò)上海市科委實(shí)驗(yàn)動(dòng)物管理監(jiān)督執(zhí)法的檢查，合乎有關(guān)國(guó)家標(biāo)準(zhǔn)要求，設(shè)施獲得實(shí)驗(yàn)動(dòng)物生產(chǎn)行政許可／實(shí)驗(yàn)動(dòng)物生產(chǎn)行政許可。P2實(shí)驗(yàn)室該設(shè)施經(jīng)過(guò)上海市金山區(qū)衛(wèi)生監(jiān)督所監(jiān)督執(zhí)法檢查，合乎國(guó)家及上海市有關(guān)規(guī)定，設(shè)施取得上海市病原微生物學(xué)實(shí)驗(yàn)室備案憑證。P3動(dòng)物實(shí)驗(yàn)該設(shè)施經(jīng)過(guò)國(guó)家認(rèn)可委認(rèn)可及國(guó)家衛(wèi)健委評(píng)審，合乎國(guó)家有關(guān)規(guī)定、國(guó)家標(biāo)準(zhǔn)的要求，獲得ABSL3實(shí)驗(yàn)室及實(shí)驗(yàn)活動(dòng)資質(zhì)。擬實(shí)驗(yàn)時(shí)間：年月日至年月日Experimentalperiod:YMDtoYMD擬實(shí)驗(yàn)地點(diǎn)：Experimentalplace:動(dòng)物實(shí)驗(yàn)項(xiàng)目的目的、必要性、意義和如何設(shè)計(jì)以達(dá)成研究目標(biāo)的Experimentalobjective,necessityandsignificanceandhowtheprogramhasbeendesignedtoachievetheobjectivesoftheresearch。擬使用動(dòng)物信息AnimaltobeUsed動(dòng)物來(lái)源Animalorigin許可證編號(hào)Certificatenumber質(zhì)量合格證Certificationoffitness□有□無(wú)品種/品系Breed/strain□大鼠rat□小鼠mouse□裸鼠nudemouse□兔rabbit□犬dog□靈長(zhǎng)類primateanimal□轉(zhuǎn)基因動(dòng)物geneticallymodifiedanimal□其他（具體說(shuō)明）others等級(jí)Grade□普通CV□清潔CL□SPF□無(wú)菌GF□其他數(shù)量只（♀♂）Number（♀♂）體重gWeightg月齡MAgemoon擬使用動(dòng)物信息Animaltobeused選擇實(shí)驗(yàn)動(dòng)物種類和數(shù)量的原因Reasonsforthechoiceofspeciesandnumbersofanimalstobeused擬開展動(dòng)物實(shí)驗(yàn)的詳細(xì)信息DescriptionInformationOftheExperimentsOnAnimals詳細(xì)列出對(duì)動(dòng)物可能造成的所有可預(yù)期的傷害，包括動(dòng)物運(yùn)輸、每個(gè)實(shí)驗(yàn)方案、動(dòng)物飼養(yǎng)方式、實(shí)驗(yàn)操作步驟中等可能產(chǎn)生傷害、疼痛或不適的細(xì)節(jié)以及擬采取的防控措施Descriptionoftheoverallharmsexpectedtobeexperiencedbytheanimals-includingdetailsofthelikelyadverseeffectsofeachprotocol,cagebreedingandthestepswhichwillbetakentocontroltheseadverseeffects擬開展動(dòng)物實(shí)驗(yàn)的詳細(xì)信息Detailedinformat-ionoftheexperime-ntsonanimals主要觀察指標(biāo)Mainobservationtargets主要實(shí)驗(yàn)方法MainExperimentalmethods仁慈終點(diǎn)或?qū)嶒?yàn)終結(jié)的指標(biāo)Humaneendpointorexperimentalterminativeindicator擬開展動(dòng)物實(shí)驗(yàn)的詳細(xì)信息Detaile-dinforma-tionoftheexperim-entsonanimals動(dòng)物處死方法Deathconduct非處死動(dòng)物的處置方式Notforthedeathoftheanimaldisposition□繼續(xù)使用Continuetouse□保存的機(jī)構(gòu)Saveintheagency□放生野外Releasetothewild□其他，詳細(xì)說(shuō)明Others,detaileddescription動(dòng)物替代、減少動(dòng)物用量、降低動(dòng)物痛苦傷害的主要措施Majormeasurefor3Rs是否使用有毒(害)物質(zhì)(感染、放射、化學(xué)毒、其他)Poisonous(harmful)material(infection,radiate,chemicalpoisonandother)beingused□否no□是yes說(shuō)明：Declare利害分析的小結(jié)，說(shuō)明為何預(yù)期的利益多于害處?Asummaryoftheharm-benefitanalysis—whytheexpectedbenefitsmightbeconsideredtoout-weighthepredictedharms?相關(guān)的補(bǔ)充說(shuō)明或輔助證明文件Supplementaryinstructionoranyauxiliarydocumentsforinvestigate信息公開和保密要求:說(shuō)明哪些信息需要保密，哪些信息可以公開Declarationfortheinformationdisclosureandconfidentialityrequirements,declaringtheinformationneedtobekeptsecrettheinformationcanbedisclosed對(duì)倫理委員有無(wú)回避要求Claimingjurorsforbeingdebarb.聲明:1.我將自覺(jué)遵守實(shí)驗(yàn)動(dòng)物福利倫理相關(guān)法規(guī)和各項(xiàng)規(guī)定,同意接受倫理委員會(huì)和實(shí)驗(yàn)動(dòng)物室管理者的監(jiān)督與檢查。2.本人保證本申請(qǐng)表中所填內(nèi)容真實(shí)、詳盡和易懂。Declaration:1.Iwillabidebythelawandregulationstipulation,andacceptthesupervisionandinspectionbythecommitteeandlaboratoryanimaldepartment2.TheinformationIhavegivenisaccurate,detailedandcomprehensive聲明人:課題負(fù)責(zé)人簽(章)Declarant:Signature(stamp)ofPI年月日YND獸醫(yī)／動(dòng)物設(shè)施意見OpinionofVeterinaryofInstitutionorfromLaboratoryAnimalFacility主管獸醫(yī)／設(shè)施負(fù)責(zé)人簽（章）：Signature(stamp)ofVeterinaryorFacilityDirector年月日YND主管部門意見Opinionofthedepartmentincharge主管部門負(fù)責(zé)人簽（章）：Signature（stamp）ofScientificresearchdepartment