Form 4 Foreign Annual Report

OMB Number 0925-0765
Expiration Date: xx/xxxx

Annual Report to OLAW for Foreign Institutions

Institution [in English]:      

Assurance Number:      

Reporting Period:      

This Institution, through the Authorized Institutional Official, provides this Annual Report to the Office of Laboratory Animal Welfare (OLAW) of the United States Department of Health and Human Services.

1. Funding [MUST COMPLETE THIS SECTION]

Live, vertebrate animal activity that is supported by the Public Health Service (PHS)*, National Science Foundation (NSF), or National Aeronautics and Space Administration (NASA):

[ ] Is not currently conducted at this Institution [Skip to II]

[ ] Is currently conducted at this Institution and funded by [Select all that apply]:

[ ] PHS*

[ ] NSF

[ ] NASA

*PHS funding sources include the Centers for Disease Control and Prevention (CDC), Food and Drug Administration (FDA), National Institutes of Health (NIH), and Biomedical Advanced Research and Development Authority (BARDA).

2. Compliance [MUST COMPLETE THIS SECTION]

[ ] There were no reportable noncompliances or animal activity suspensions to report to the OLAW Division of Compliance Oversight, during this reporting period [Skip to III]

[ ] This Institution, through the Authorized Institutional Official, provided reports to the OLAW Division of Compliance Oversight, during this reporting period.

[Visit https://olaw.nih.gov/guidance/reporting-noncompliance.htm for reporting guidance]

3. Accreditation [MUST COMPLETE THIS SECTION]

[ ] No changes to AAALAC International (AAALAC) accreditation status [Skip to IV]

[ ] AAALAC accreditation status has changed [Choose one]

[ ] AAALAC Accredited

[ ] Non-Accredited

4. Certification [MUST COMPLETE THIS SECTION]

[ ] No changes to Canadian Council on Animal Care (CCAC) certification status [Skip to V]

[ ] CCAC certification status has changed [Choose one]

[ ] CCAC Certified

[ ] Non-Certified

[Provide all written answers in English]

5. Institutional Commitment [MUST COMPLETE THIS SECTION IN ENGLISH]

[ ] No changes to Institutional Commitment [Skip to VI]

There are changes to Institutional Commitment: [Complete one or both of the following items]

[ ] The listed laws, regulations, and/or policies previously agreed upon in the approved Foreign Assurance document or previous Annual Reports to OLAW no longer apply to the Institution’s Foreign Assurance. [List titles in English of all governing laws, regulations, and policies for your jurisdiction that are no longer applicable.]

[ ] The listed laws, regulations, and/or policies are new applicable provisions that apply to the Institution’s Foreign Assurance. [List titles in English of all additional applicable governing laws, regulations, and policies for your jurisdiction.]

6. Description of Oversight [MUST COMPLETE THIS SECTION IN ENGLISH]

[ ] No changes to Description of Oversight [Skip to VII]

[ ] The Description of Oversight has changed. [Provide a description of the changes to this section of the approved Foreign Assurance document or previous Annual Reports to OLAW.]

7. Authorized Institutional Official [MUST COMPLETE THIS SECTION]

[ ] No change in Authorized Institutional Official [Skip to VIII]

[ ] The new Authorized Institutional Official’s information is included below.

Name, Credentials:
Title [in English]:
Address: [street, city/town, state/province/other, postal code, country]
Phone:	E-mail:

8. Institutional Contacts [MUST COMPLETE THIS SECTION]

[ ] No change in Institutional Contacts [Skip to IX]

[ ] Changes in Institutional Contacts are included below. [Two Institutional Contacts other than the Authorized Institutional Official are required for each Foreign Assurance. Examples include chairperson, animal or review committee member, institutional representative, regulatory official, veterinarian, or grants official. If removing an Institutional Contact, a replacement Institutional Contact must be provided.]

Removal of Previous Institutional Contacts

Name:

E-mail:

Name:

E-mail:

Addition of Institutional Contacts
Name, Credentials:
Title [in English]:
Name of Institution [in English]:
Phone:	E-mail:

Name, Credentials:
Title [in English]:
Name of Institution [in English]:
Phone:	E-mail:

9. Other Changes [MUST COMPLETE THIS SECTION IN ENGLISH]

[ ] No other changes [Skip to X]

[ ] There are other changes to the information in the approved Foreign Assurance document or previous Annual Reports to OLAW. [Provide a description of the changes in English.]

10. Signature [MUST COMPLETE THIS SECTION]

Authorized Institutional Official

Name, Credentials:

Signature:

Date:

Statement of Burden

Public reporting burden for this collection of information is estimated to average 90 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.

Foreign Annual Report to OLAW v2022 2