ࡱ> AC@a bjbj *,F\F\ \1333333$:WWl11d5{0 %   WW  > J: Incident Report Form LOYOLA UNIVERSITY Chicago Health sciences division Institutional ANIMAL CARE AND USE COMMITTEE (IACUC) Bldg. 115, Room 248 Phone: (708) 216-4288 Fax: (708) 216-9399  HYPERLINK "mailto:avalero@luc.edu" avalero@luc.edu This form should be used to notify the IACUC of an animal welfare complaint, any unusual or unexpected observation while performing experimental procedures which may require an amendment to the protocol, an inadvertent protocol deviation, an incident noted during post-approval monitoring, and/or a possible protocol violation. The form should be completed and submitted to the IACUC Office. ( Complaint Perceived deficiencies in husbandry standards, inhumane treatment of animals, research misconduct, facilities operations, administration/IACUC management and/or the safety/security of animals or other related deficiencies that reflect on our federal assurance or the quality of care and use of these animals. ( Unusual/Unexpected Observation Any unexpected experimental outcome that may require a modification to an approved animal care and use protocol. ( Incident Review Inadvertent protocol deviation by one of the individuals listed on the ACORP, which may be perceived as requiring IACUC review. ( Oversight Report Observations made during routine post- approval monitoring of an animal protocol. ( Possible Protocol Violation May include animal use without IACUC approval or an activity being conducted that is not in accordance with the description of that activity provided by the Principal Investigator in the ACORP and approved by the IACUC. DESCRIPTION OF THE INCIDENT: DATE AND TIME OF REPORT:LOCATION: PRINCIPAL INVESTIGATOR/LAB SUPERVISOR RESPONSIBLE:EMAIL:BLDG./ROOM:LU#: P/D#SPECIES INVOLVED:REPORTED BY:  PRINCIPAL INVESTIGATOR/LAB SUPERVISORS COMMENTS:  TO BE COMPLETED BY CMF STAFFCMF VERIFICATION/COMMENTS:  TO BE COMPLETED BY IACUCIACUC RECOMMENDATIONS/ACTIONS:  Initiating such concerns via the appropriate channels in no way places an employee, volunteer, student or other staff member at risk to be discriminated against or be subject to any reprisal for reporting perceived violations of any standard or regulation. 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