1、動物實驗倫理審查表編號(N?)：The Tab of Animal Experimental Ethical Inspection申請單位 (Name of organization) ：單位地址 (Address) ：實驗項目名稱 (Study title) ：經費來源及代碼（Source of funds and code ）：實驗目的 (Aim of experiment) ：實驗方法 (experimental methods):觀測指標 (observational index):實驗結束后處死動物的方法(executing animal method ):擬動物來源 (Source

2、 of animal) ：進品種品系 (Species or strain)：等級 (Grade)：規(guī)格 (Specifications) ：動物數量 (Number) ：只 (只；只 )申請日期 (Application date) ：年月日情況進駐日期 (Entering date)：年月日結束日期 (Ending date) ：年月日申請人簽名崗位證書編號技術職稱聯系電話(Signature of applicant)(Number of permit)(Professional title)(Telephone)1. 該項目是否必須用實驗動物進行實驗，即能否用計算機模擬、細胞培養(yǎng)等非生

3、命方法替代動物或用低等動物替代高等動物進行實驗 (Does laboratory animal must be used in the project? Could other methods such as computer審查依據(Inspectioncontents)simulation, cell cultivation or using the low-grade animal instead of the high-grade animal)？2. 表中所填申請人資格和所用動物的品種品系、質量等級、規(guī)格是否合適，能否通過改良設計方案或用高質量的動物來減少所用動物的數量(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. 能否通過改進實驗方法、調整實驗觀測指標、改良處死動物的方法，來優(yōu)化實驗方案、善待動物(Could thestudy design and animal treatment be refined by a

5、meliorating experimental method, adjusting observational index, executing animalmethod) ？我將自覺遵守實驗動物福利倫理原則，隨時接受委員會的監(jiān)督與檢查，如違反規(guī)定， 自愿接受處罰。 (I will abideby the laboratory animal welfare ethics principle, ready to accept the Commission of supervision.Otherwise,I will voluntarily accept the punishment .)聲明

6、(Declaration)負責人意見同意不同意(Study director) ：(Agree)(Disagree)審查結果( 是否同意申請人的實驗動物部主任意見同意不同意實驗方案 )(Director of Dept. ofLab (Results ofAnimal Science)：(Agree)(Disagree)inspection)醫(yī)學部實驗動物福利與倫理委員會意見同意不同意(The Animal Care&(Disagree)Welfare Committee)：(Agree)項目負責人簽（章）(Signature)：項目執(zhí)行人簽（章）(Signature)：年月日簽名(S

7、ignature)簽名(Signature)簽章(Stamp)備注 (Supplement)：實驗動物設施使用證明編號 (N?)：The Certification of Using the housing facility of Laboratory Animal使用單位 (Name of organization) ：實驗名稱 (Name of experiment) ：倫理審查表編號(Number of animalexperimental ethical investigational tab) ：使用者簽名 (Signature of user)：來 源質量合格證編號 (Number

8、使用動物情況(Source)：of qualitative qualificat ion)：(Situation品種品系 (Species or strain)：等級 (Grade)：of usinglaboratory數量 (Quantity) ：只 (只；只 )規(guī)格 (Specifications) ：animal)進駐日期 (Entering date)：年月日結束日期 (Ending date)：年月 日屏障本設施的環(huán)境條件符合中國國家標準實驗動物環(huán)境及設施（ GB14925-2001 ）對屏障動設施(barrierhousingfacility)物實驗設施的有關標準，動物飼養(yǎng)管理和動

9、物實驗操作符合北京市實驗動物管理條例等法規(guī)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)。飼養(yǎng)設施條件普通(Condition設施ofthe(Ordinaryhousinghousingfacilities)facility)本設施的環(huán)境條件符合中國國家標準實驗動物環(huán)境及設施（ GB14925-2001 ）對普通動物實驗設施的有關標準，動物飼養(yǎng)管理和動物實驗操作符合上海市實驗動物管理條例等法規(guī)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)。許可證編號有效期 (Term自年月日設施使of validity) ：至年月日(Number of permit)：用許可(Permit of許可證發(fā)放機構上海市市科學技術委員會the facility)(Permitting organization) ：(Shanghai Municipal Committee of Science and Technology)實驗設施負責人意見(Head of the project) ：動物實驗中心主任意見(Directorof animal experimental center)：所實驗動物管委會意見(TheA