课题名称(Project   name)：

申请人姓名(applicant name)：         技术职称(Technical title)：       岗位证书编号(Post certificate number)：   动字（    ）第     号

项目负责人(Project Leader)：           技术职称(Technical title)：       联系电话(Contact phone)：                     手机(Mobile phone)：

申请者单位或部门(Applicant unit or department)：                 负责人(Leader)：

拟进

动物

情况

动物来源(Animal   resources)：

品种品系(Species or strains)：              等级(Grade)：        规格(Specifications)：   

数量(quantity)：   只(其中：♀  只；♂   只)

申购日期(Date   of purchase)：    年(year)  月(month)    日(day)

进驻日期(Entering date)：   年(year)  月(month)    日(day)

结束日期(End   date)：       年(year)  月(month)    日(day)

遵守实验动物福利原则的声明：本人已阅读了《江西中医药大学实验动物伦理委员会章程》，本人及其项目组成员将严格遵守国际通行的动物福利和伦理准则，贯彻执行国家和江西省有关实验动物管理法律、法规和政策，善待实验动物。

Declaration   of compliance with the principles of animal welfare: I have read the “constitution of the   experimental animal ethics committee of Jiangxi University of traditional   Chinese Medicine”, I and the project team members will strictly abide by the   international animal welfare and ethical standards, carry out the   relevant laws, regulations and policies on the management of laboratory   animals in Jiangxi Province, and care laboratory animals.

项目负责人签名(Project Leader   signature)：         

实验要点,包括：实验目的、实验方法、观测指标、实验结束后处置动物的方法等(Experimental points, including: the   experimental purpose, experimental methods, observation indicators, assays   for animal sacrifice, etc. after the end of the experiment)

实验目的(Experimental purpose)：

实验方法(Experimental methods)：

观测指标(Observation indicators)：

实验结束后处置动物的方法（包括处置的方式等）(Assays for animal sacrifice, etc. after the end of the experiment, including methods to   end animal life, etc.)：

手术过程中动物福利保障措施（包括减轻动物痛苦措施等）(Safeguard measures for animal welfare during operation, including   measures to alleviate the pain of animals, etc.)：

危险物品、药品安全处置措施（包括针头、有害药品的安全处置措施等）(Safety management measures of hazardous substances, drug,   including safety management measures of needles, the safe disposal of   hazardous drugs, etc. )：

审查

依据

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、细胞培养等非生命方法替代动物或用低等动物替代高等动物进行实验。(1.Whether the project must be carried out with laboratory   animals, Whether higher animal used to animal experiments can be substituted   by computer simulation, cell culture, other non life alternatives or low   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。(2. whether the applicant qualifications, animal strains or lines   used, quality grades, specifications are suitable, whether the number of   animals used can be reduced by improving the design scheme or the use of high   quality animals)

3.    能否通过改进实验方法、调整实验观测指标、改良处置动物的方法，来优化实验方案、善待动物。(3.Whether animal experiment can be   optimized and animal can be cared through improving experimental method,   adjusting the observation index, and improving the disposition of an   animal)

4.    保证动物福利的相关措施是否落实。(4. Whether   the relevant measures to ensure implementation of animal welfare were carried   out)

主管单位负责人意见(Comments of the   person in charge of the competent authority)：

                                                     签章(signature)

 年(year)  月(month)    日(day)

伦理委员会评审决议(Ethics committee review decision)：

                  伦理委员会主任委员签章(Ethics   committee chairman signature)

年(year)  月(month)    日(day)