附件二動(dòng)物實(shí)驗(yàn)福利倫理審查報(bào)告ApplicationFormForWelfare&EthicalInspectioninAnimalExperimentation、基本信息(BasicInformation)實(shí)驗(yàn)項(xiàng)目名稱NameofResearchProject項(xiàng)目負(fù)責(zé)人姓名NameofApplicant職稱/職務(wù)Professionaltitle電話/傳真Telephone/FAX電子郵件E-mail單位名稱NameofInstitute動(dòng)物實(shí)驗(yàn)設(shè)施名稱NameofAnimalfacility許可證編號No.ofLicense動(dòng)物實(shí)驗(yàn)設(shè)施地點(diǎn)AddressofAnimalFacility實(shí)驗(yàn)周期ExperimentalPeriodsFrom: mm dd yyyyTO mm dd yyyy、直接進(jìn)行動(dòng)物實(shí)驗(yàn)的人員資料(InformationofPersonnelresponsibleforanimalcare&use)：姓名Name性別Gender職稱/職務(wù)Professionaltitle崗位證書編號No.ofCertification動(dòng)物實(shí)驗(yàn)經(jīng)驗(yàn)ExperienceofAnimalExperiment□有Experienced□需要市教UnderthesupervisionofotherExperiencedpersonnel□有Experienced□需要市教UnderthesupervisionofotherExperiencedpersonnel□有Experienced□需要市教UnderthesupervisionofotherExperiencedpersonnel三、實(shí)驗(yàn)動(dòng)物信息(LaboratoryAnimalsInformation)動(dòng)物品種/品系A(chǔ)nimalSpecies年齡/體重Age/Weight數(shù)量(Quantity)供應(yīng)單位及許可證編號Supplier早占1.2.3.四、 動(dòng)物飼養(yǎng)(AnimalBreeding)由動(dòng)物中心專人負(fù)責(zé)(Chargingbyspecialpersonintheanimalcenter)；由實(shí)驗(yàn)室人員負(fù)責(zé)，負(fù)責(zé)人姓名(Chargingbylabstaff,nameofprinciple)：五、 簡述下列實(shí)驗(yàn)步驟(Describethefollowingexperimentstepinbrief)：使用麻醉藥品名稱及麻醉方式(NameandMethodsofAnaesthesia)：注：使用超過一種實(shí)驗(yàn)動(dòng)物時(shí)，須分別填報(bào)每種動(dòng)物所使用之藥品劑量(Intheoccasionthatmorethanonesortofanimalisneeded,Pleasefillouttheleechdomdosagethateachsortanimalisused.)。無須麻醉原因(ThereasonofnoAnaesthesia)：若動(dòng)物需長時(shí)間保定超過四小時(shí)，請說明所用器械與方法 (Ifanimalshouldbeimplementedrestraintformorethan4hours,PleasedescribetheMethodsofrestraint)：六、請說明實(shí)驗(yàn)結(jié)束后動(dòng)物的處置方式(Pleaseexplainthedisposalmethodsofanimalafterexperiment)：(1)實(shí)驗(yàn)后動(dòng)物疼痛處理及照顧辦法(Thetendancemethodsforanimalafterexperiment)：安樂死的方法(Methodsofeuthanasia)：尸體處理辦法(Disposalofcarcase)：□委托動(dòng)物中心處理(Consignittoanimalcenter) □其它:(Others)本人保證以上所填數(shù)據(jù)完全屬實(shí)(Iassurethattheabovedataistrue.)項(xiàng)目負(fù)責(zé)人簽字(SignatureofApplicant):單位蓋章(SealofInstitution)：填報(bào)日期(Date)月(MM)日(DD)年(YYYY)

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