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Institutional Animal Care and Use Committee
ADVERSE EVENT/Unanticipated Problem Form
Adverse Event: Any happening not consistent with routine expected outcomes that results in any unexpected animal welfare issues (death, disease, or distress) or human health risks (zoonotic diseases or injuries). If you are having a significant number of deaths, and even though it does not relate to non-compliance, it should be reported to the IACUC and the University Veterinarian.
ADMINISTRATIVE
Instructions: All materials must be typed, signed and submitted immediately to: IACUC Chairperson, MNS Building or scan the signed form and email to HYPERLINK "mailto:IACUC@rwu.edu" IACUC@rwu.edu.Protocol Number:Protocol Title:
Principal Investigator:Phone:Email:Mailing Address:City:State: Zip:ADVERSE EVENT/UNANTICIPATED PROBLEM INFORMATION
Event/Problem Date:Location of Event/Problem:Severity of Event/Problem:ModerateSevereFatalIs this event/problem related to the research:RelatedPossibly RelatedNot RelatedDescription of the event/problem (include cause, outcome):Description of how the event/problem was managed:Provide a description of the corrective and preventative actions taken to ensure this type of event/problem does not occur in the future:Does this event/problem necessitate a change in the protocol?
If yes, please complete and submit to the IACUC chairperson the Changes in Protocol Form.YesNo
Signature of Principal Investigator
Date
OFFICE USE ONLYCheck all that applyInitialDateConsultation with IACUC ChairCopy sent to IACUC Committee for their information; filed with protocol no further action required.Forward to IACUC for review and actionWrite to PI with concerns/schedule PAM visitForward form to Provost Report to OLAWReport to USDA
Adverse Event/Unanticipated Outcome Form
09-02-09
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