Bowdoin



Adverse Event Form – Animal Research

This form is to be submitted to the Research Oversight Committee (ROC) when an event occurs that results in a change in the welfare of the animals or in a change to the protocol procedures. Events that should be reported include (but are not limited to) the creation of conditions that jeopardize the health or well being of animals, including natural disasters, accidents, and mechanical failures, resulting in actual harm or death to animals.

This form must be completed and submitted to the ROC as soon as possible after the occurrence of an adverse event, and no later than 10 working days from when the investigator becomes aware of the event.

The Committee will use the submitted information to determine whether or not the risk-benefit ratio continues to be acceptable, and whether or not the protocol activities need to be revised to accurately reflect such events.

Today’s Date:      

ROC Approval #:      

Protocol Title:      

Principal Investigator:      

Faculty Advisor (if P.I is not a faculty member):      

Number of animals enrolled to date:      

Animal Information

Number of animals involved in this event:      

Species:      

Identification Number(s):      

Event Description (include what happened, when and where):      

Outcome of Event:      

Were study procedures delayed or stopped for this or any other animal due to this event?      

Was the event expected due to study procedures?      

Was the event related to study procedures?      

If YES, is the possibility of this event included in the currently approved protocol?      

If YES, please specify where in the protocol this risk may be found.      

If NO, please submit a modification form to add the possibility of this event occurring to the protocol.      

By signing below, I certify that the answers provided on this form are complete and accurate. I assure that all protocol activities will take place in accordance with state, federal and college regulations.

Signature of Principal Investigator Date Signature of Faculty Advisor

(if Principal Investigator is not Faculty)

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