ࡱ> SpRO ,-bjbj3O3O *2Q%eQ%eJ+ O.O.O.O.O.c.c.c.8.<.,c.8h//////// 0 0 08888888$;=689O. 0 0 0 0 068O.O.////o8d1d1d1 0FO.//O.//8d1 08d1d1n6\7//;3P0F7 7808<7 u>0du>@\7u>O.\7 0 0d1 0 0 0 0 068680j 0 0 08 0 0 0 0u> 0 0 0 0 0 0 0 0 0 -: Revised 03/2020 ĶƵapp INSTITUTIONAL ANIMAL CARE AND USE COMMITTEE (IACUC) STUDENT RESEARCH ASSISTANT TRAINING CERTIFICATION This form must be completed by all students (undergraduate and graduate) prior to their involvement in any animal research protocol. A separate form is required for each student and each animal research protocol in which the student participates. The form must be co-signed by the Faculty Advisor and the Animal Caretaker. Protocol # _________________ Faculty Investigator: ____________________________________ (List only ONE protocol per form) Research Assistant: _____________________________________ Title of the Protocol: __________________________________________________________________ (List FULL TITLE of protocol) SECTION I. STUDENT or INVESTIGATOR CERTIFICATION: I am a: % Student Researcher (Sections I-V must be completed) % Faculty Investigator I hereby certify that I (please check off when completed): __ have read the animal research protocol listed above __ have completed CITI Lab Animal Welfare Training ( HYPERLINK "http://www.citiprogram.org" www.citiprogram.org; attach completion report) __ have familiarized myself with the contents of the Tutorial on the Public Health Service Policy on Humane Care and Use of Laboratory Animals found at http://grants.nih.gov/grants/olaw/tutorial/index.htm __ have received complete training from the Animal Caretaker in the maintenance procedures of the Animal Facility. __ will not perform animal research without direct supervision until I receive proper training and can competently perform the appropriate procedures (STUDENT ONLY; Complete Training in Techniques) ______________________________ ______________________________ __________________ _________________________________ ________________________________________ _________________ Signature of Student or Investigator Printed Name of Student or Investigator Date SECTION II. ANIMAL CARETAKER CERTIFICATION: I hereby certify that ________________________________, a student who will be working on the animal (Printed Name of Student) protocol listed above, has received training in the maintenance procedures of the _____________________ Animal Facility. _____________________________ ________________ Signature of Animal Caretaker Date SECTION III. TRAINER CERTIFICATION: I hereby certify that ______________________________ has received full training on the following dates: ___________________________________, and has demonstrated competence to perform the following surgical techniques and/or specialized husbandry procedure without direct supervision: SECTION IV. FACULTY INVESTIGATOR CERTIFICATION: I hereby certify that ________________________________, a student who will be working on the animal (Printed Name of Student) protocol listed above, has read the research protocol, watched the videotapes, familiarized him/herself with the PHS Policy Tutorial, and received training from the Animal Caretaker. I further certify that this student will not perform animal research without direct supervision until s/he is properly trained and can competently perform the appropriate procedures. ______________________________ ___________________ Signature of Faculty Investigator Date SECTION V. 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