IndianaUniversityPurdueUniversityatIndianapolis.docVIP

INSTITUTIONAL BIOSAFETY COMMITTEE Protocol Submission Form For new protocols or those involving the use of recombinant DNA in research INSTRUCTIONS (indicate type of submission): All submissions – must be typed. Submit to Research Services, Granada Center Suite 400. If off campus, submit to 6439 N. Sheridan, Suite 400, Chicago, IL 60626. Call 773 508-2689 for additional forms and information. Keep a copy for your records. **To indicate a checked box, double click the box and indicate “checked” as the default value. rDNA submissions - submit the original application plus 11 copies to the address above. Transgenic/Knockout rodent submission (purchase or transfer only) – complete Sections I through V and Sections IX through X. Submit one original and one copy of the application. SECTION I. – GENERAL PROJECT DETAILS Investigator Name: Department: Campus Address: Phone: Email: Fax: Primary Contact: Campus Address: Email: Phone: Title of Protocol: Funding: Internally funded Externally funded. Source: Grant/sponsor number: New Study Ongoing Research Project Title: Sponsor(s) of the research: Human Subjects Research (IRB) Protocol number: Most recent approval date: Animal Research (IACUC) Previously approved: Protocol number: Most recent approval date: Pending Date submitted: SECTION II. RESEARCH SUMMARY Please summarize the proposed research. Limit your discussion to one page. Note that “See Attached” with the attachment of a grant narrative is unacceptable. Provide a basic description and rationale for your project. Describe what systems you plan to use, including any animal work, your endpoint, and what type of manipulations you plan to use to achieve that goal. If the experiment is conducted in more than one room, or if different