Admin SOP 2.3 - Subcommittee Workflow

University Animal Care Committee Standard Operating Procedure

Document No: UACC 2.3

Subject: Subcommittee Workflow

Date Issued: September 27, 2023

Revision: Original

Location: Queen’s University

Purpose: The purpose of this Standard Operating Procedure (SOP) is to describe the procedural workflow for the UACC Subcommittee.


1. Introduction and Definitions:

The UACC Subcommittee is a small representation of the full committee. It consists of the Chair, the University Veterinarian, and a community member and conducts defined reviews on behalf of the UACC.


  • University Animal Care Committee UACC
  • Principal Investigator PI
  • Animal Use Protocol AUP
  • Canadian Council on Animal Care CCAC

2. Procedures:

The UACC delegates specific reviews to the Subcommittee for final acceptance at the full UACC. These include:

  • Level A protocols
  • Level B-D Protocol Renewals
  • Minor Amendments
  • Pilot Progress Reports/Extensions
  • Interim Reviews

At the discretion of the UACC Subcommittee, any review may be referred to the full UACC for review.

Level A Protocols

Level A new and full resubmission protocols are reviewed and approved by the UACC Subcommittee whereas Level A renewals are reviewed and approved by the UACC Coordinator. The CCAC does not require animal use protocols for level A work, however the UACC has found it beneficial to maintain records for level A protocols where invertebrates are housed in animal facilities on campus.

Level B-D Protocol Renewals

Level B-D protocol renewals are reviewed by the UACC Subcommittee whereas level E renewals are reviewed and approved by the full UACC. Monthly reminders are circulated at least 3 times prior to the renewal date. Renewal submissions must describe all new changes to the protocol and provide a progress report on the outcome of the last approval period. This includes complications encountered relative to animal health and welfare and how they were resolved as well as the adequacy of the humane interventions and study endpoints and a description of the use and distribution of animals as compared to that which was previously approved. To facilitate continuity, renewals should ideally be submitted at least 2 weeks before their renewal date.

Minor Amendments

As defined in the Policy on Protocol Amendments, changes which may affect animal use or welfare, but do not increase the category of invasiveness are classified as Minor and can be reviewed by the UACC Subcommittee (e.g.: Increase in total animal numbers (rodent, fish and wildlife) up to 25% that previously approved).

Pilot Progress Reports/Extensions

At time of renewal, regardless of whether the study is to continue, a pilot progress report must be completed. Pilot extensions of up to 1 year are available if nothing is changing within the application and little or no progress was made during the initial 1-year period.

Interim Reviews

Urgent reviews that are required prior to the next scheduled meeting of the UACC can be initially reviewed by the Subcommittee if clear justification is provided. Interim approvals are subject to discussion and final approval at a full UACC meeting. Questions and/or additional recommendations may still be provided following the full UACC review.

Inter-Institutional Collaborations

All animal work affiliated with Queen’s University, whether occurring at Queen’s (but with funds flowing through another institution) or occurring elsewhere (but with funds flowing through Queen’s or involving Queen’s personnel in other capacities) requires prior approval of the Queen’s UACC.

Generally, the institution managing the funding for the work is classified as the “home” institution and the institution where the work takes place, the “host”. Proposals where Queen’s is the home institution should be submitted in the electronic protocol management system (Topaz Elements). When Queen’s is the host (e.g.: externals users conducting research / teaching at QUBS) the home approved protocols will be attached in the electronic protocol management system to facilitate review and record management. The reverse process is also accepted (host protocol approved first and submitted for home review/approval). The UACC Coordinator manages the creation of interinstitutional protocols in the system.

Protocol Revisions

All UACC reviews that are returned for modification are either designated for subsequent administrative, subcommittee or full UACC follow-up review within the initial motion. Revisions designated for Subcommittee are assigned accordingly upon resubmission. Protocols may be returned multiple times before being accepted for approval.

Subcommittee Reviews Report

The UACC reviews for approval, all actions of the Subcommittee since the last UACC meeting by way of the Subcommittee Reviews Report which is submitted to each monthly meeting. To ensure transparency, the report provides a comment summary as sent to the PI (regardless of the review outcome) and tracks the dates for submission, assignment, return for modification and where in the cycle the protocol currently sits (i.e., pending, returned for modification, approved).

Subcommittee Review Timelines

All subcommittee reviews are assigned as promptly as possible provided they are deemed suitable to proceed following preliminary review. Review due dates of roughly 4-5 days are typically assigned unless an urgency requiring prompter review is highlighted and justified.

Review delays can be impacted for a number of reasons:

  • only 1 individual (UACC Coordinator) facilitates the assignment/processing of all reviews
  • subcommittee consists of only 3 individuals-all 3 must reach an outcome by consensus
  • if a conflict of interest is declared within the subcommittee an alternate must be sought
  • absence of the UACC Coordinator or any subcommittee member often results in delays
  • the presence of very high assignment volume will often result in delays

Date New Version
09/27/2023 Created and Approved


Admin SOP 2.3 - Subcommittee Workflow

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