Send your completed form and supporting documentation to: Agriculture Victoria Wildlife and Small Institutions Animal Ethics Committee Executive Officer 475 Mickleham Road Attwood VIC 3049 Or by email: wsi.aec@ecodev.vic.gov.au

General information

Non-compliance with WSIAEC approval and conditions of approval and Victorian legislation including the Australian Code for the care and use of animals for scientific purposes is a serious matter.

Alleviating unanticipated pain and distress to the animal(s) must take precedence over an individual animal reaching the planned endpoint of the project, or the continuation or completion of the project. If necessary, animals must be humanely killed without delay.

This form serves to provide information to the WSIAEC where there has been non-compliance or alleged non-compliance to facilitate investigation of the event.

You are directed to the WSIAEC non-compliance procedure for information regarding the investigation of non-compliance.

This form is to be completed by the responsible investigator or eligible institution, as applicable.

Completion of this form may be instigated by a responsible person or eligible institution on becoming aware that non-compliance has occurred or may be requested by the WSIAEC as part of the investigation process of a complaint or adverse event.

In the event that non-compliance has impacted on animal welfare the WSIAEC incident event form (adverse event form) must also be completed.

This report is a summary of the details of the incident and the actions being taken to prevent recurrence.

Eligible institution or individual

Eligible institution (Licence holder) or individual approved to access the WSIAEC: Enter name here

Eligible institution nominee or affiliated organisation: Enter name here

Date of submission of report: Enter date here

Project details

Project title: Enter project name(s) here

WSIAEC approval number : Enter WSIAEC approval number(s) here

Project chief investigator : Enter name here

Project approval date : Enter date here

Project expiry date : Enter date here

Scientific Procedures Premises Licence/ Scientific Procedures Fieldwork License/ Specified Animal Breeding Licence number (where applicable) : Enter Licence number here

Name of person making report: Enter name here

Provide a brief summary of the project: Enter response here

Non-compliant event details

Did this event adversely impact on animal wefare? If yes a unexpected adverse event form must be completed.

Enter response here

Provide a timeline of events. When was the incident first identified and when was the WSIAEC notified of the event? Document steps taken to manage the incident by listing dates, times, events, actions taken and by whom.

Enter response here

What caused the event to occur?

Enter response here

A comprehensive review of this and related projects must be undertaken to determine whether this event is symptomatic of more widespread non-complinace.

Enter information regarding the scope and the review and findings here

What strategies have been implemented to return to compliance and prevent a recurrence of non-compliance?

Enter response here

WSIAEC Privacy Statement

The Department of Economic Development, Jobs, Transport and Resources (DEDJTR) is committed to protecting personal information provided by you in accordance with the principles of the Victorian privacy laws. The information you provide will be used for the purposes of the function of the Wildlife and Small Institutions Animal Ethics Committee (WSIAEC) which is administered according to the Prevention of Cruelty to Animals (POCTA) Act 1986 and regulations 2008 and the terms of reference of the WSIAEC. The information you provide will be made available to members of the WSIAEC, The Minister for Agriculture and DEDJRT employees administering the POCTA Act and may be disclosed to another government organisation for the purpose of administering or enforcing the Catchment and Land Protection Act 1994, Wildlife Act 1975, Prevention of Cruelty to Animals Act 1986 or other relevant state, territory or commonwealth legislation. If all requested information including correspondence and related documents is not received the WSIAEC will be unable to adequately assess or review your application or approved project. This may result in your application not being considered by the WSIAEC or suspension of approval of a project. You may access the information you have provided to DEDJTR by contacting Department of Economic Development, Jobs, Transport

OFFICE USE ONLY This non-compliant event report has been reviewed by the Wildlife and Small Institutions Animal Ethics Committee The WSIAEC considered the report in terms of compliance with the approved project and relevant legislation including the Australian Code for the care and use of animals for scientific purposes. Comments (include whether an unexpected adverse event report or any other report was required). Enter comments here Date report considered by the WSIAEC: Enter date here

and Resources, WSIAEC Executive Officer, 475 Mickleham Road, Attwood, Victoria 3049.