CCAC policy statement on: the certification of animal ethics and care programs



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Canadian Council on Animal Care Conseil canadien de protection des animaux CCAC policy statement on: the certification of animal ethics and care programs Date of Publication: January 2016 1. CCAC CERTIFICATION PROCESS The Canadian Council on Animal Care (CCAC) assesses and certifies animal ethics and care programs of organizations conducting animal-based work in research, teaching, testing or production (of animals or biologics for scientific purposes). An institution s animal ethics and care program is certified based on institutional compliance with CCAC standards (policy statements and guidelines) and other relevant standards (see Appendix I, Requirements for Obtaining a First CCAC Certificate, and Appendix II, Requirements for Maintaining CCAC Certification ). This compliance is assessed through: institutional documentation CCAC site visits institutional responses to CCAC recommendations The certification process takes place every three years. A visual depiction of the certification processes is given in Appendix III, Timeline for CCAC Certification, and Appendix IV, Timeline for a First CCAC Certification. Additional information on the Assessment and Certification Program can be found in the 2014 CCAC policy statement on: definitions of recommendations made in CCAC reports. 1.1 CCAC Certificates Two types of certificates can be awarded by the CCAC Assessment and Certification Committee on behalf of the CCAC: the CCAC Certificate of GAP Good Animal Practice and the CCAC Probationary Certificate of GAP Good Animal Practice. CCAC policy statement 1.1.1 CCAC Certificate of GAP Good Animal Practice The CCAC Certificate of GAP Good Animal Practice is awarded to institutions with sound animal ethics and care programs, as determined by the CCAC Assessment and Certification Committee working with the CCAC assessment panel or associate director of assessments that has visited the institution.

An institution may receive the CCAC Certificate of GAP Good Animal Practice if: the CCAC report produced following the CCAC visit contains no recommendations, or the CCAC report contains Major recommendations for which the institution has taken immediate and appropriate action, or Serious or Regular recommendations for which the institution provides one or more implementation reports that are satisfactory to the Assessment and Certification Committee; and the institution is in good standing ( in good standing applies to an institution that has paid its Annual Program Participation Fee in accordance with CCAC requirements). 1.1.2 CCAC Probationary Certificate of GAP Good Animal Practice The CCAC Probationary Certificate of GAP Good Animal Practice is assigned to either: CCAC policy statement institutions that only have a theoretical animal ethics and care program in place and are seeking their first certification any institution that has significant, unresolved deficiencies in their animal ethics and care program, as determined by the CCAC Assessment and Certification Committee working with the CCAC assessment panel that has visited the institution The Probationary Certificate is valid for a maximum of one year. An institution may be assigned a CCAC Probationary Certificate of GAP Good Animal Practice if, for example: it meets the requirements for an initial Probationary Certificate (see Appendix I of this policy) the CCAC assessment report contains Serious or Regular recommendations, and the institution does not submit the required implementation report(s) the CCAC assessment report contains Serious recommendations for which the institution submits a response that is not satisfactory to the CCAC Assessment and Certification Committee, working with the assessment panel(s) An institution in difficulty assigned a Probationary Certificate is given specific deadlines within the probationary year to respond to the CCAC s recommendations, and the CCAC Assessment and Certification Committee evaluates the progress made by the institution at each deadline. The Assessment and Certification Committee may remove the Probationary Certificate of GAP Good Animal Practice if recommendations are not addressed to the satisfaction of the Assessment and Certification Committee within the given time frames. A thorough review of the institution s progress is undertaken at the end of the probationary period, and the institution s category of certification is also reviewed. 2

2. REMOVAL OF THE CCAC CERTIFICATE OF GAP GOOD ANIMAL PRACTICE OR THE PROBATIONARY CERTIFICATE OF GAP GOOD ANIMAL PRACTICE AND CHANGES IN CATEGORY OF CERTIFICATION An institution s CCAC Certificate of GAP Good Animal Practice or Probationary Certificate of GAP Good Animal Practice will be removed if: after being issued a Major recommendation in response to an immediate and significant threat to animal health and welfare found during a CCAC visit, the institution does not take immediate appropriate action after being assigned a Probationary Certificate, the institution fails to respond to the CCAC Assessment and Certification Committee s satisfaction to Serious recommendations contained in CCAC reports, despite being given a specified period in which to do so an institution is no longer in good standing with the CCAC ( in good standing applies to an institution that has paid its Annual Program Participation Fee in accordance with CCAC requirements) An institution that loses its Certificate will have its name removed from the CCAC list of certificate holders posted on the CCAC website. Other consequences of certificate removal and changes in category of certification are detailed below for academic, government and private institutions. 2.1 Academic Institutions The senior administrator responsible for the animal ethics and care program in an academic institution, and the senior administrator responsible for animal care policy at the federal granting agencies are notified through a letter from the CCAC Executive Director when there is a change in the category of certification for an institution, when an institution: loses its Certificate of GAP Good Animal Practice and receives a Probationary Certificate of GAP Good Animal Practice loses its Certificate of GAP Good Animal Practice or its Probationary Certificate of GAP Good Animal Practice regains a Probationary Certificate of GAP Good Animal Practice regains a Certificate of GAP Good Animal Practice voluntarily relinquishes its Certificate of GAP Good Animal Practice the certification of animal ethics and care programs, 2016 The federal granting agencies require that all institutions that use animals for research hold valid CCAC certification (either the Certificate of GAP Good Animal Practice or the Probationary Certificate of GAP Good Animal Practice ) in order to be eligible for agency research funds. The 2013 federal granting agency Agreement on the Administration of Agency Grants and Awards by Research Institutions, and in particular Section 3.5, Research Involving Animals, specifies the 3

responsibilities of institutions that use animals for research and wish to be eligible for and retain granting agency funds. Removal of CCAC certification from an institution that uses animals for research and is eligible to receive agency funding constitutes a breach of the Agreement, which would be addressed as specified in Section 4.4, Default and Remedies of the Agency Agreement. 2.2 Government Institutions Senior administrators with overall responsibility for the animal ethics and care program in government institutions are notified if any of their units lose certification or have any other change in their category of certification. 2.3 Private Institutions The Chief Executive Officer of a private institution is notified if the institution loses its certification or has any other change in its category of certification. 3. CHANGES WITHIN A CERTIFIED PROGRAM CCAC policy statement Certified institutions must advise the CCAC before any of the following planned major changes to their program are implemented: significant change(s) in the structure of the animal ethics and care program, such as: a new faculty, department, research centre or other unit in which animals will be used changes in senior positions changes in reporting lines significant change(s) in the types of animals used or the nature of the work conducted with them (such as introduction of animal-based research in an institution that has only used animals for teaching, introduction of mammals in an institution that has only used non-mammalian species, new use of animals requiring specialized personnel and equipment, for example introduction of non-human primates) significant change(s) in structure or function of the animal care committee or committee(s) resignation, retirement or replacement of senior members of the animal ethics and care program (senior administrator, animal care committee chair, veterinarian(s), facility director/manager), or changes in responsibilities of personnel new animal facilities or major renovations to existing ones (i.e. 30% or more of the existing facility is affected by the renovation) The CCAC will take any such changes under advisement and decide whether more information or a CCAC visit is necessary. 4

Appendix I Requirements for Obtaining a First CCAC Certificate Institutions that only have a theoretical animal ethics and care program in place wishing to be certified for the first time by obtaining a Probationary Certificate of GAP Good Animal Practice are invited to contact the CCAC Assessment and Certification Program for guidance and information tailored to their particular situation. All institutions wishing to obtain a first Certificate will be required to pay an annual program participation fee to the CCAC and must have the following elements in place before their first CCAC assessment visit: compliance with provincial legislation and regulations an animal care committee, whose composition, authority, responsibilities and functioning are defined in written Terms of Reference based on the most recent version of the CCAC policy statement on: terms of reference for animal care committees an animal use protocol form (or forms), according to the guidance contained in the CCAC policy statement on: terms of reference for animal care committees complete protocols submitted by animal users for all planned animal-based work, with the animal care committee having reviewed and made decisions on any protocols planned for the near future. The protocol reviews should be based on relevant guidance (as found in the CCAC policy statement on: terms of reference for animal care committees, Section 3e) and documented in the minutes of one or more animal care committee meetings a formal agreement or agreements for veterinary services, based on the main elements of the Canadian Association for Laboratory Animal Medicine Standards of Veterinary Care trained, qualified personnel in sufficient numbers to care for all groups of animals seven days a week programs based on CCAC guidance for: the training of animal users post-approval monitoring occupational health and safety, to cover all animal project related risks crisis management where animal facilities are needed, they must either meet relevant CCAC guidance or a detailed plan with timelines must be in place describing how they will be improved to meet the guidance the animal care committee must have visited all facilities designated for animal care or use, and must have approved of their use in one or more written site visit report(s) the certification of animal ethics and care programs, 2016 5

Appendix II Requirements for Maintaining CCAC Certification Institutions wishing to maintain Canadian Council on Animal Care (CCAC) certification must ensure that: CCAC policy statement they are compliant with provincial legislation and regulations their animal care committee remains active and functional, meeting at least twice every year, visiting all animal facilities at least once every year and fulfilling all of the responsibilities described in the CCAC policy statement on: terms of reference for animal care committees, including post-approval monitoring of animal ethics and care their veterinary and animal care services continue to meet institutional needs and CCAC standards their training, occupational health and safety and crisis management programs are relevant, complete, up-to-date and in line with CCAC guidance their facilities (if required) meet institutional needs and CCAC standards they are in good standing with the CCAC Annual Program Participation Fees 6

Appendix III Timeline for CCAC Certification At 8.5 months: If information received from institution is complete CCAC RESPONSIBILITIES Assessment visit At 2.5 months (10 weeks): Assessment report sent to institution 2 Between 5.5 and 6.5 months: Possibility of requesting an update on implementation of Serious recommendations 4,6 Between 8.5 and 10 months: Possibility of requesting additional updates 5,6 TIME (IN MONTHS) 0 3 6 9 INSTITUTIONAL RESPONSIBILITIES One month before the assessment visit: Pre-assessment documentation received from institution 1 At 5.5 months (3 months after receiving assessment report): If Serious recommendations, implementation report due 3 At 8.5 months (6 months after receiving assessment report): If Regular recommendations, implementation report due 3 the certification of animal ethics and care programs, 2016 Analysis of implementation reports and updates within 10 weeks by the Assessment and Certification Committee (AACC) collaborating with the assessment panel; decision on certification by the AACC At 13 months 12 15 At 13 months: Final deadline for institution to send updated information 7

CCAC policy statement 1 Institutions are asked to submit pre-assessment documentation (program review form or program review form for interim visits) to the CCAC three to four weeks before the assessment visit. 2 Assessment reports are normally sent to the institution within ten weeks of the visit. Certification will occur as soon as the CCAC Assessment and Certification Committee is satisfied that the institutional animal ethics and care program meets all relevant CCAC requirements. This can be at the time the assessment report is sent to the institution (within two and a half months) if there are no recommendations, or at any later time during the assessment process. 3 If the assessment report contains recommendations, institutions are asked to address them in an implementation report. Serious recommendations must be addressed within 3 months of receiving the assessment report, and Regular recommendations within 6 months. The CCAC normally addresses any institutional response to recommendations within ten weeks, making the certification process generally shorter when implementation reports are received before the deadlines. 4 The institution should normally respond to this update request with the implementation report on Regular recommendations. 5 In the majority of cases, the CCAC will limit its requests for updates on the implementation of recommendations to two letters per institution, prior to certification. 6 Updates can take any of the following forms: written documents, information provided by telephone or the organization of a special visit to the institution. 8

Appendix IV Timeline for a First CCAC Certification For institutions with a theoretical animal ethics and care program in place seeking their first certification CCAC RESPONSIBILITIES First assessment visit: Conducted by Associate Director of Assessment At 1.5 months (6 weeks): Brief report and Probationary Certificate of GAP Good Animal Practice sent to institution if no serious concerns are identfied 2 TIME (IN MONTHS) 0 3 6 INSTITUTIONAL RESPONSIBILITIES Prior to first assessment visit to institution: Institution will be provided with information about the CCAC Program and will receive an orientation or virtual visit One month before first assessment visit by an Associate Director of Assessment: Pre-assessment documentation should be received from institution 1 the certification of animal ethics and care programs, 2016 12 At 13.5 months: Deadline for institution to receive a CCAC Certificate of GAP Good Animal Practice 3 15 9

1 Institutions are asked to submit pre-assessment documentation (program review form or program review form for interim visits) to the CCAC three to four weeks before the assessment visit. 2 If serious concerns are identified during the first assessment visit to an institution seeking its initial Probationary Certificate of GAP Good Animal Practice, the institution will not be certified until the concerns are addressed. 3 Institutions that first receive a Probationary Certificate of GAP Good Animal Practice must become fully certified within 12 months of receiving the Probationary Certificate. An accelerated certification process, based on Appendix III, Timeline for CCAC Certification, will be put into place to ensure this. CCAC policy statement 10 For more information on these and other policies contact: Canadian Council on Animal Care 190 O Connor St., Suite 800 Ottawa, ON, Canada K2P 2R3 Tel.: (613) 238-4031 Fax: (613) 238-2837 ccac@ccac.ca http://www.ccac.ca