Request to Grant an Ethical Authorization to a Field Expert

Ethical Authorization to a Field Expert in Protocol # *

Principal Investigator

Name *

Affiliation (Department, Institute) *

E-mail *

Cell Phone *

Ethical Authorization # *

Type/s of Animals working with *

Title and number of requested protocol/s *

Requested Expert

Name *

Affiliation (Department, Institute) *

Israeli ID / Passport # *

E-mail *

Cell Phone *

Field of Expertise *

Does exists Ethical Authorization number? *

Yes

Attach relevant documents *

For Field Experts that hold Authorization Certificates to work with animals in research - please attach the relevant certificate/s of the requested Expert. For certificates of Courses taken abroad - please attach the syllabus of the relevant course/s for the relevant type of animal.
More information

Files must be less than 2 MB.
Allowed file types: gif jpg jpeg png html pdf doc docx.

Type/s of Animals the expert will work with *

Reason for the request of authorization: please describe the procedure, the animal species involved, the lack of experience in the PI’s lab, the advantage of involving the expert. *

Time frame for the expert to be engaged in the research *

Location of research (where the expert will work) *

Please detail whether or not this is a onetime request. If it is for repetitive procedures, please specify the expected time intervals or timeline *

PI's Declaration

I hereby declare that the above expert will perform the requested procedure/s under my direct supervision, or under the supervision of: *

permanent authorization certificate number *

granted to him / her by the Hebrew University in year *

to perform scientific experiments on animals of the following classes: *

Submitting PI's name *

FOR OFFICE USE ONLY - please don't fill.

Recommendation:

Name

Remarks

Date

Day

Month

Year

Committee Decision (approved / not approved) and Remarks:

Name

Decision

Remarks

Date

Day

Month

Year

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