Form 4 Annual Report

OMB Number 0925-xxxx
Expiration Date: xx/xxxx

Annual Report to OLAW

Institution:

Assurance Number:

Reporting Period:

This institution's Institutional Animal Care and Use Committee (IACUC), through the Institutional Official, provides this annual report to the Office of Laboratory Animal Welfare (OLAW).

1. Program Changes [Select A or B]

[   ]	There have been no changes in this institution's program for animal care and use as described in the Assurance. [Skip to Item II.]
[   ]	Change(s) in this institution’s program for animal care and use as described in the Assurance have occurred during this reporting period.
	Select all that apply:
	[   ]	This institution’s AAALAC accreditation status has changed (PHS Policy IV.A.2.).
		[   ]	AAALAC Accredited – Category 1
		[   ]	Non-Accredited – Category 2
	[   ]	This institution’s program for animal care and use has changed (PHS Policy IV.A.1.a-i.). [Attach a full description of the changes.]
	[   ]	The individual designated by this institution as the Institutional Official has changed. [Provide name, title(s), address, e-mail, phone, and fax numbers in Item V.]
	[   ]	The membership of this institution’s IACUC has changed. [Provide current roster of members in Item VI.]

2. Semiannual Evaluations

This IACUC has conducted semiannual evaluations of the institution’s program and inspections of the institution’s facilities (including satellite facilities) on the dates below. Reports of the evaluations and inspections have been submitted to the Institutional Official. The reports include any IACUC-approved departures from the Guide with a reason for each departure, any deficiencies (significant or minor) that were identified, and a plan and schedule for correction of each deficiency. [Do not provide semiannual reports unless they include a minority view.]

1. Program Evaluations

[Two dates (month/day/year) must be provided to satisfy the PHS Policy requirement that evaluations be done at 6-month intervals. If the IACUC conducted more than 2 evaluations of the program during the reporting period, please attach a list showing the dates.]

Date 1:

Date 2:

2. Facility Inspections

[Two dates (month/day/year) must be provided to satisfy the PHS Policy requirement that facility inspections be done at 6-month intervals. If the IACUC conducted more than 2 inspections of each site during the reporting period, please attach a list showing the dates.]

Date 1:

Date 2:

3. Minority Views [Select A or B]

[   ]	There were no minority views during this reporting cycle.
[   ]	Any minority views submitted by members of the IACUC regarding reports filed under PHS Policy IV.F. for this reporting cycle are attached.

4. Signatures

IACUC Chairperson	Institutional Official
Name:	Name:
Signature:	Signature:
Date:	Date:

5. Change in Institutional Official

Name:
Title:	Degree/Credentials:
Name of Institution:
Address: [street, city, state, zip code]
Phone:	Fax:
E-mail:

6. Change in IACUC Membership [Current roster]

Institution:
IACUC Contact Information
Address: [street, city, state, zip code]
E-mail:
Phone:					Fax:
IACUC Chairperson
Name:
Title:					Degree/Credentials:
PHS Policy Membership Requirements***:
IACUC Roster [Provide below or attach]
Name of Member/ Code*			Degree/ Credentials	Position Title/ Occupational Background**		PHS Policy Membership Requirements***
	* Names of members, other than the chairperson and veterinarian, may be represented by a number or symbol in this report to OLAW. Sufficient information to determine that all appointees are appropriately qualified must be provided and the identity of each member must be readily ascertainable by the institution and available to authorized OLAW or other PHS representatives upon request.
	** List specific position titles for all members, including nonaffiliated (e.g., banker, teacher, volunteer fireman; not “community member” or “retired”).
	*** PHS Policy Membership Requirements:
	Veterinarian	veterinarian with training or experience in laboratory animal science and medicine or in the use of the species at the institution, who has direct or delegated program authority and responsibility for activities involving animals at the institution.
	Scientist	practicing scientist experienced in research involving animals.
	Nonscientist	member whose primary concerns are in a nonscientific area (e.g., ethicist, lawyer, member of the clergy).
	Nonaffiliated	individual who is not affiliated with the institution in any way other than as a member of the IACUC and is not a member of the immediate family of a person who is affiliated with the institution. This member is expected to represent general community interests in the proper care and use of animals and should not be a laboratory animal user. A consulting veterinarian may not be considered nonaffiliated.
	[Note: all members must be appointed by the Chief Executive Officer (or individual with specific written delegation to appoint members) and must be voting members. Non-voting members and alternate members must be so identified.]

Statement of Burden

Public reporting burden for this collection of information is estimated to average 90 minutes 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.

Annual Report v06/27/2019 4