Form 2 Foreign Assurance

OMB Number 0925-xxxx

Expiration Date: xx/xxxx

Animal Welfare Assurance for Foreign Institutions

Name of Institution:

Address: [street, city/town, state/province/other, postal code, country]

This Institution agrees to comply with the Public Health Service (PHS) Policy on Humane Care and Use of Laboratory Animals (Policy), or provide evidence that acceptable standards for the humane care and use of the animals in PHS-conducted or supported activities will be met.

1. Applicability

This Animal Welfare Assurance for Foreign Institutions (Foreign Assurance) is applicable to all research, research training, and biological testing activities involving live, vertebrate animals supported by the PHS, the US Department of Health and Human Services, and the National Science Foundation and conducted at this institution. This Assurance covers only those facilities and components listed below.

1. The following are branches and components over which this institution has legal authority, including those that operate under a different name: [List only institutions that will conduct animal research on the grant or contract. All institutions listed must be under the Assured institution’s legal, financial, and administrative authority. MUST COMPLETE THIS SECTION]

   
   

2. The following are other institutions or branches and components of another institution: [List only institutions that will conduct animal research as a subgrant or subcontract. They must be recipients of PHS funding or pending PHS award. MUST COMPLETE THIS SECTION]

2. Institutional Commitment

This Institution is guided by the International Guiding Principles for Biomedical Research Involving Animals (PDF). This Institution will comply with all applicable provisions of the following laws, regulations, and policies governing the care and use of laboratory animals. [List titles in English of all governing laws, regulations, and policies for your jurisdiction. MUST COMPLETE THIS SECTION]

This Institution acknowledges and accepts responsibility for the care and use of animals involved in activities covered by this Foreign Assurance. As partial fulfillment of this responsibility, this Institution 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 all applicable laws, regulations, and policies pertaining to animal care and use.

Check one: [MUST COMPLETE THIS SECTION]

[ ] This Institution is accredited by AAALAC International.

[ ] This Institution is not accredited by AAALAC International.

Check one: [MUST COMPLETE THIS SECTION]

[ ] This Institution is accredited by Canadian Council on Animal Care.

[ ] This Institution is not accredited by Canadian Council on Animal Care.

3. Notification

This institution agrees to notify OLAW when contact information changes. This information can be e-mailed to olawdoa@mail.nih.gov or sent by fax to: +1 (301) 451-5672. Include Foreign Assurance number in all correspondence.

4. Institutional Endorsement and PHS Approval

A. Authorized Institutional Official [MUST COMPLETE THIS SECTION]
Name:
Title:
Name of Institution:
Address: [street, city/town, state/province/other, postal code, country]
Phone:	Fax:
E-mail:
Signature:	Date (month/day/year):

B. PHS Approving Official [to be completed by OLAW]
Name/Title: Office of Laboratory Animal Welfare (OLAW) National Institutes of Health Bethesda, Maryland USA Phone: +1 (301) 496-7163 Fax: +1 (301) 451-5672
Signature:	Date:
Foreign Assurance Number:
Effective Date:	Expiration Date:

5. Institutional Contacts

Two additional Institutional contacts are required. Examples include: chairperson, animal, or review committee member, institutional representative, regulatory official, veterinarian, or grants official. [MUST COMPLETE THIS SECTION]

Contact #1
Name:
Title:
Name of Institution:
Address: [street, city/town, state/province/other, postal code, country]
Phone:	Fax:
E-mail:

Contact #2
Name:
Title:
Name of Institution:
Address: [street, city/town, state/province/other, postal code, country]
Phone:	Fax:
E-mail:

Statement of Burden

Public reporting burden for this collection of information is estimated to average 1 hour per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-xxxx*). Do not return the completed form to this address.

Foreign Assurance v06/27/2019 3