Form 1 Interinstitutional Assurance (IA) for Domestic

OMB Number 0925-xxxx

Expiration Date: xx/xxxx

Interinstitutional Assurance for a Domestic Performance Site

The Interinstitutional Assurance is used by awardee institutions that receive Public Health Service (PHS) funds through a grant or contract award when the institution has neither its own animal care and use program, facilities to house animals, nor an Institutional Animal Care and Use Committee (IACUC) and will conduct the animal activity at an Assured domestic institution (named as a performance site).

I.Awardee Institution

Name of Awardee Institution:

Address: [street, city, state, zip code]

Project Title: [title of grant application or contract proposal]

Grant or Contract Number:

Principal Investigator:

1. Applicability

This Interinstitutional Assurance between the awardee institution and the Assured domestic institution is applicable to research, research training, and biological testing involving live vertebrate animals supported by the PHS and conducted at the Assured institution.

2. Awardee and Assured Institutional Responsibilities

1. The institutions agree to comply with all applicable provisions of the Animal Welfare Act and other Federal statutes and regulations relating to animals.

2. The institutions agree to be guided by the U.S. Government Principles for the Utilization and Care of Vertebrate Animals Used in Testing, Research, and Training and comply with the PHS Policy on Humane Care and Use of Laboratory Animals (Policy).

3. The institutions acknowledge and accept responsibility for the care and use of animals involved in activities covered by this Assurance. As partial fulfillment of this responsibility, the institutions will make a reasonable effort to ensure that all individuals involved in the care and use of laboratory animals understand their individual and collective responsibilities for compliance with this Assurance, as well as all other applicable laws and regulations pertaining to animal care and use.

4. The awardee institution acknowledges and accepts the authority of the IACUC of the Assured institution where the animal activity will be performed and agrees to abide by all conditions and determinations as set forth by that IACUC.

Name of Assured Domestic Institution:

Domestic Assurance Number:

Address: [street, city, state, zip code]

2. Institutional Endorsement

By signing this document, the authorized official at the awardee institution and the Institutional Official (IO) and IACUC Chairperson at the Assured domestic institution (performance site) provide their assurances that the project identified in Part I will be conducted in compliance with the PHS Policy and the Assurance of the domestic institution.

Endorsement of Awardee Institution
Name of Awardee Institution:
Authorized Official:
Signature:		Date:
Title:
Address: [street, city, state, zip code]
Phone:	Fax:
E-mail:
Endorsement of Assured Domestic Institution
Name of Assured Institution:
Institutional Official*:
Signature:		Date:
Title:
Address: [street, city, state, zip code]
Phone:	Fax:
E-mail:
IACUC Chairperson*:
Signature:		Date:
Title:
Address: [street, city, state, zip code]
Phone:	Fax:
E-mail:
Date of IACUC Approval: [within 3 years, pending not acceptable]
[*Both the IO of record (or person with signature authority for the IO) and the IACUC Chairperson of record (or designee verifying IACUC review and approval) must sign.]

3. PHS Approval [to be completed by OLAW]

Signature of OLAW Official:		Date:
Name/Title: Office of Laboratory Animal Welfare (OLAW) National Institutes of Health Bethesda, Maryland Phone: +1 (301) 496-7163 Fax: +1 (301) 451-5672
Grant/Contract #:	Animal Welfare Assurance #:
Effective Date:	Expiration Date: (duration of project, up to 5 years)

Statement of Burden

Public reporting burden for this collection of information is estimated to average 30 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-xxxx*). Do not return the completed form to this address.

Interinstitutional Assurance for Domestic Site v06/27/2019 3