Interinstitutional
Assurance
The
Interinstitutional Assurance is used by U.S. institutions that receive Public Health Service (PHS) funds through a grant
or contract award when the institution has neither its own animal care and use program, facilities
to house animals, nor an Institutional Animal Care and Use Committee (IACUC)
and will conduct the animal activity at an Assured
institution (named as a performance site).
Name of Awardee Institution: |
Address: (street
address, city, state, zip code) |
Project Title: (from grant application/contract proposal) |
Grant/Contract Number: |
Principal Investigator: |
A. Applicability
This Interinstitutional Assurance between the awardee institution and the
Assured institution is applicable to research, research training, and
biological testing involving live vertebrate animals supported by the PHS and conducted
at the Assured institution.
B. Awardee and Assured Institutional Responsibilities
i.
The institutions agree to comply with all
applicable provisions of the Animal Welfare Act and other Federal statutes and
regulations relating to animals.
ii.
The institutions agree to be guided by the U.S.
Government Principles for the Utilization and Care of Vertebrate Animals Used
in Testing, Research, and Training and comply with the PHS Policy on Humane
Care and Use of Laboratory Animals (Policy).
iii.
The institutions acknowledge and accept
responsibility for the care and use of animals involved in activities covered
by this Assurance. As partial fulfillment of this responsibility, the institutions
will make a reasonable effort to ensure that all individuals involved in the
care and use of laboratory animals understand their individual and collective
responsibilities for compliance with this Assurance, as well as all other
applicable laws and regulations pertaining to animal care and use.
iv.
The awardee institution
acknowledges and accepts the authority of the IACUC of the Assured institution
where the animal activity will be performed and agrees to abide by all
conditions and determinations as set forth by that IACUC.
Name of Assured Institution: |
Address: (street
address, city, state, zip code) |
By signing this document, the authorized official at the awardee
institution and the Institutional Official and IACUC Chairperson at the Assured
institution (performance site) provide their assurances that the project identified
in Part I will be conducted in compliance with the PHS
Policy and the Assurance of the Assured institution.
A. Endorsement of Awardee Institution |
||
Name of Awardee
Institution: |
||
Authorized Official: |
||
Signature: |
Date: |
|
Title: |
||
Address: (street
address, city, state, zip code) |
||
Phone: |
Fax: |
|
E-mail: |
||
B. Endorsement of Assured Institution |
||
Name of Assured
Institution: |
||
Institutional Official: |
||
Signature: |
Date: |
|
Title: |
||
Address: (street
address, city, state, zip code) |
||
Phone:� |
Fax: |
|
E-mail: |
||
IACUC Chairperson: |
||
Signature: |
Date: |
|
Title: |
||
Address: (street
address, city, state, zip code) |
||
Phone:� |
Fax: |
|
E-mail: |
||
Date of IACUC Approval: (within 3 years, pending not acceptable) |
||
III.
PHS Approval (to be completed by OLAW)
Signature of OLAW Official: |
Date: |
|
Office of Laboratory
Animal Welfare (OLAW) National Institutes of
Health 6705 Rockledge Drive RKL1, Suite 360, MSC
7982 Bethesda, MD 20892-7982
(express mail zip code 20817) Phone: (301) 496-7163���������� Fax: (301) 915-9465 |
||
Grant/Contract #: |
Animal
Welfare Assurance #: |
|
Effective Date: |
Expiration Date: (duration of project, up to 5 years) |
|