动物实验伦理审查表

1、动物实验伦理审查表编号(N?)：The Tab of Animal Experimental Ethical Inspection申请单位 (Name of organization) ：单位地址 (Address) ：实验项目名称 (Study title) ：经费来源及代码（Source of funds and code ）：实验目的 (Aim of experiment) ：实验方法 (experimental methods):观测指标 (observational index):实验结束后处死动物的方法(executing animal method ):拟动物来源 (Source

2、 of animal) ：进品种品系 (Species or strain)：等级 (Grade)：规格 (Specifications) ：动物数量 (Number) ：只 (只；只 )申请日期 (Application date) ：年月日情况进驻日期 (Entering date)：年月日结束日期 (Ending date) ：年月日申请人签名岗位证书编号技术职称联系电话(Signature of applicant)(Number of permit)(Professional title)(Telephone)1. 该项目是否必须用实验动物进行实验，即能否用计算机模拟、细胞培养等非生

3、命方法替代动物或用低等动物替代高等动物进行实验 (Does laboratory animal must be used in the project? Could other methods such as computer审查依据(Inspectioncontents)simulation, cell cultivation or using the low-grade animal instead of the high-grade animal)？2. 表中所填申请人资格和所用动物的品种品系、质量等级、规格是否合适，能否通过改良设计方案或用高质量的动物来减少所用动物的数量(Are th

4、e qualification of applicant ，species or strain, grade and specifications of animalssuitable? Could the quantity of animals be reduced by improving the study design or using high quality animals)？3. 能否通过改进实验方法、调整实验观测指标、改良处死动物的方法，来优化实验方案、善待动物(Could thestudy design and animal treatment be refined by a

5、meliorating experimental method, adjusting observational index, executing animalmethod) ？我将自觉遵守实验动物福利伦理原则，随时接受委员会的监督与检查，如违反规定， 自愿接受处罚。 (I will abideby the laboratory animal welfare ethics principle, ready to accept the Commission of supervision.Otherwise,I will voluntarily accept the punishment .)声明

6、(Declaration)负责人意见同意不同意(Study director) ：(Agree)(Disagree)审查结果( 是否同意申请人的实验动物部主任意见同意不同意实验方案 )(Director of Dept. ofLab (Results ofAnimal Science)：(Agree)(Disagree)inspection)医学部实验动物福利与伦理委员会意见同意不同意(The Animal Care&(Disagree)Welfare Committee)：(Agree)项目负责人签（章）(Signature)：项目执行人签（章）(Signature)：年月日签名(S

7、ignature)签名(Signature)签章(Stamp)备注 (Supplement)：实验动物设施使用证明编号 (N?)：The Certification of Using the housing facility of Laboratory Animal使用单位 (Name of organization) ：实验名称 (Name of experiment) ：伦理审查表编号(Number of animalexperimental ethical investigational tab) ：使用者签名 (Signature of user)：来 源质量合格证编号 (Number

8、使用动物情况(Source)：of qualitative qualificat ion)：(Situation品种品系 (Species or strain)：等级 (Grade)：of usinglaboratory数量 (Quantity) ：只 (只；只 )规格 (Specifications) ：animal)进驻日期 (Entering date)：年月日结束日期 (Ending date)：年月 日屏障本设施的环境条件符合中国国家标准实验动物环境及设施（ GB14925-2001 ）对屏障动设施(barrierhousingfacility)物实验设施的有关标准，动物饲养管理和动

9、物实验操作符合北京市实验动物管理条例等法规的要求 (This housing facilityis a barrier housing facility, and it has in keeping with national standardLaboratoryAnimal Requirements of Environment and Housing Facilities (GB 14925 2001). The care of laboratory animal andthe animal experimental operation have conforming to Beijing

10、 Administration Rule of Laboratory Animal ,et al)。饲养设施条件普通(Condition设施ofthe(Ordinaryhousinghousingfacilities)facility)本设施的环境条件符合中国国家标准实验动物环境及设施（ GB14925-2001 ）对普通动物实验设施的有关标准，动物饲养管理和动物实验操作符合上海市实验动物管理条例等法规的要求 (This housing facility is an ordinary housing facility, and it has in keeping with national s

11、tandardLaboratoryAnimal Requirements of Environment and Housing Facilities (GB 14925 2001). The care of laboratory animal andthe animal experimental operation have conforming to Shanghai Administration Rule of Laboratory Animal,et al)。许可证编号有效期 (Term自年月日设施使of validity) ：至年月日(Number of permit)：用许可(Permit of许可证发放机构上海市市科学技术委员会the facility)(Permitting organization) ：(Shanghai Municipal Committee of Science and Technology)实验设施负责人意见(Head of the project) ：动物实验中心主任意见(Directorof animal experimental center)：所实验动物管委会意见(TheA