Form 5 Interinstitutional Assurance for Foreign Performance Sit

OMB Number 0925-0765
Expiration Date: 11/30/2022

Interinstitutional Assurance for a Foreign Performance Site

The Interinstitutional Assurance may be used by institutions that are involved in a Public Health Service (PHS), National Science Foundation (NSF), or National Aeronautics and Space Administration (NASA) funded animal activity when the institution (named as Institution) lacks its own animal care and use program, facilities to house animals, or an Institutional Animal Care and Use Committee (IACUC) or Animal Welfare Committee and will conduct the animal activity at an Assured Institution (named as a performance site).

1. Awardee Institution

Name of Awardee Institution:

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

Project Title:

Award Number:

Principal Investigator:

1. Applicability

This Interinstitutional Assurance between the Awardee Institution and Assured Institution (hereinafter referred to as Institutions) is applicable to research, research training, and biological testing involving live vertebrate animals supported by the PHS, NSF, or NASA and conducted at the Assured Institution.

2. Responsibilities

1. The Institutions agree to comply with the 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, NSF, and NASA conducted or supported activities will be met as described in the approved Assurance of the Foreign Institution.

2. The Assured Foreign Institution agrees to be guided by the International Guiding Principles for Biomedical Research Involving Animals (PDF) and will comply with all applicable provisions of the laws, regulations, and policies governing the care and use of laboratory animals in the jurisdiction where the activity is conducted. The prime awardee must establish appropriate policies and procedures to ensure the humane care and use of animals and bears ultimate responsibility for compliance with the PHS Policy in all PHS, NSF, and NASA supported animal activities.

3. 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 reasonable efforts 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.

4. The Awardee Institution acknowledges and accepts the authority of the Assured Institution where the animal activity will be performed and agrees to abide by all conditions and determinations as set forth by the Assured Institution.

Name of Assured Foreign Institution:

Foreign Assurance Number:

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

2. Institutional Endorsement

By signing this document, the Authorized Official at the Awardee Institution and Institutional Official (IO) and Institutional Contact at the Assured Foreign Institution (performance site) provide their assurances that the project identified in Part I will be conducted in compliance with the PHS Policy, or in compliance with acceptable standards for the humane care and use of the animals, as described in the approved Assurance of the Foreign Institution.

Endorsement of Awardee Institution
Name of Awardee Institution:
Authorized Official:
Signature:		Date:
Title:
Address: [street, city/town, state/province/other, postal code, country]
Phone:	Fax:
E-mail:
Endorsement of Assured Foreign Institution
Name of Assured Institution:
Institutional Official*:
Signature:		Date:
Title:
Address: [street, city/town, state/province/other, postal code, country]
Phone:	Fax:
E-mail:
Institutional Contact*:
Signature:		Date:
Title:
Address: [street, city/town, state/province/other, postal code, country]
Phone:	Fax:
E-mail:
Date of IACUC or Oversight Body Approval**: [within 3 years, pending not acceptable]

[*Both the IO of record (or individual with signature authority for the IO) and one institutional contact (i.e., chairperson, animal or review committee member, institutional representative, regulatory official, veterinarian, or grants official) of record must sign. The signature of two different individuals is required.]

[**Only required if the prime awardee has an approved Domestic Assurance with OLAW]

3. PHS Approval [to be completed by OLAW]

Name/Title:
Office of Laboratory Animal Welfare (OLAW)

National Institutes of Health

Bethesda, Maryland

Phone: +1 (301) 496-7163
Fax: +1 (301) 451-5672

Signature/Date:

Award Number:

Interinstitutional Animal Welfare Assurance Number:

Valid for the duration of the specified project or up to 5 years, whichever occurs first

Effective Date:

Statement of Burden

Public reporting burden for this collection of information is estimated to average 30 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 (0925-0765). Do not return the completed form to this address.

Interinstitutional Assurance for Foreign Site v2023 2