Form 1 Interinstitutional Assurance (IA) for Foriegn

OMB Number 0925-xxxx

Expiration Date: xx/xxxx

Interinstitutional Assurance for a Foreign 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 foreign institution (named as a performance site).

I.Awardee Institution

Name of Awardee Institution:

Address: [street, city/town, state/province/other, postal code, country]

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 foreign 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. These institutions agree to comply with the PHS Policy on Humane Care and Use of Laboratory Animals (Policy), or provide evidence that acceptable standards for the humane care and use of the animals in PHS-conducted or supported activities will be met as described in the Assurance of the foreign institution.

2. The Assured foreign institution agrees to be guided by the International Guiding Principles for Biomedical Research Involving Animals (PDF) and will comply with all applicable provisions of the laws, regulations, and policies governing the care and use of laboratory animals in the jurisdiction where the activity is conducted.

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 Assured institution where the animal activity will be performed and agrees to abide by all conditions and determinations as set forth by the Assured institution.

Name of Assured Foreign Institution:

Foreign Assurance Number:

Address: [street, city/town, state/province/other, postal code, country]

2. Institutional Endorsement

By signing this document, the authorized official at the awardee institution and the Institutional Official at the Assured foreign institution (performance site) provide their assurances that the project identified in Part I will be conducted in compliance with the PHS Policy, or provide evidence that acceptable standards for the humane care and use of the animals will be met as described in the Assurance of the foreign institution.

Endorsement of Awardee Institution
Name of Awardee Institution:
Authorized Official:
Signature:		Date:
Title:
Address: [street, city/town, state/province/other, postal code, country]
Phone:	Fax:
E-mail:
Endorsement of Assured Foreign Institution
Name of Assured Institution:
Institutional Official:
Signature:		Date:
Title:
Address: [street, city/town, state/province/other, postal code, country]
Phone:	Fax:
E-mail:
Additional Contact*:
Signature:		Date:
Title:
Address: [street, city/town, state/province/other, postal code, country]
Phone:	Fax:
E-mail:
[*One additional contact (i.e., chairperson, animal or review committee member, institutional representative, regulatory official, veterinarian or grants official) for the foreign institution is required.]

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 USA 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 Foreign Site v06/27/19 3