8 Interinstitutional Assurance Triad for Domestic Performa

OMB Number 0925-0765
Expiration Date: xx/xxxx

Interinstitutional Assurance for a Domestic Performance Site

The Interinstitutional Assurance may be used by institutions that are involved in a Public Health Service (PHS), National Science Foundation (NSF), or National Aeronautics and Space Administration (NASA) funded animal activity when the institution (named as Institution) lacks its own animal care and use program, facilities to house animals, or an Institutional Animal Care and Use Committee (IACUC) or Animal Welfare Committee and will conduct the animal activity at an Assured Institution (named as a performance site).

1. Institution

Name of Institution:

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

Project Role (or Relationship to Project): [e.g., subawardee, collaborator]

Awardee Institution

Name of Awardee Institution:

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

Project Title:

Award Number:

Principal Investigator:

1. Applicability

This Interinstitutional Assurance between the Institution, Awardee Institution, and Assured Institution (hereinafter referred to as Institutions) is applicable to research, research training, and biological testing involving live vertebrate animals supported by the PHS, NSF, or NASA and conducted at the Assured Institution.

2. 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). The prime awardee must establish appropriate policies and procedures to ensure the humane care and use of animals and bears ultimate responsibility for compliance with the PHS Policy in all PHS, NSF, and NASA supported animal activities.

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 reasonable efforts 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 Institutions acknowledge and accept 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]

3. Verification of IACUC Approval

Date of IACUC Approval [within 3 years; pending not acceptable]:

2. Institutional Endorsement

By signing this document, the Authorized Official at the Institution, 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 approved Assurance of the Domestic Institution.

Endorsement of Institution
Name of Institution:
Authorized Official:
Signature:			Date:
Title:
Address: [street, city, state, zip code]
Phone:	Fax:
E-mail:
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:
[*Both the IO of record (or individual with signature authority for the IO) and the IACUC Chairperson of record (or designee verifying IACUC review and approval) must sign. The signature of two different individuals is required.]

3. PHS Approval [to be completed by OLAW]

Name/Title:
Office of Laboratory Animal Welfare (OLAW)

National Institutes of Health

Bethesda, Maryland

Phone: +1 (301) 496-7163
Fax: +1 (301) 451-5672

Signature/Date:

Award Number:

Interinstitutional Animal Welfare Assurance Number of Institution:

Interinstitutional Animal Welfare Assurance Number of Awardee Institution (if applicable):

Valid for the duration of the specified project or up to 5 years, whichever occurs first

Effective Date:

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 (0925-0765). Do not return the completed form to this address.

Interinstitutional Assurance Triad for Domestic Site v2023 4