How to Write a Standard Operating Procedure for

Lakehead University Animal Care and Use

Why do we need Standard Operating Procedures?

A Standard Operating Procedure (SOP) is a set of instructions that someone follows to ensure work is
done safely, humanely, accurately, and efficiently. Animal Care and Use SOPs are reviewed and
approved by the Lakehead University Animal Care Committee (ACC). The SOPs are a tool the ACC uses
to ensure that the work on animals meets a high standard of care and humane use. These SOPs
establish who is to do the procedure, what qualifications are required to perform the procedure,
materials required to perform the procedure, and how the procedure will be carried out in detailed
step-by-step instructions. The researcher can be assured that the procedures are carried out
consistently to preserve data integrity, as well as assist in finding reasons for data discrepancies. Once
written, these SOPs can save researchers valuable time, as they can simply reference these SOPs in their
Animal Use Protocol (AUP) applications without having to re-write these procedures. These SOPs can
be a valuable reference and teaching tool for employees or researchers.

When to write an SOP?

 Routine procedures for animal care or facility maintenance.

 When the procedure will be used more than once.
 When the details of the procedure are lengthy (i.e. more than one page).
 When veterinary input is required (e.g. anaesthesia, surgery, invasive animal procedures such as
tagging or injections, euthanasia)
 When standardized methods are needed to give consistent results.
 When there are multiple users or persons performing the procedure.

When not to write an SOP?

 If the description of the procedure is brief enough to be described adequately in the body of the
AUP (i.e. less than one page).
 If the procedure will only be performed once.
 If the procedure is very specific to one AUP submission

If there is an approved SOP that accurately describes a procedure, but a minor modification is needed
for a particular AUP, the SOP can be referenced and a description of the modification can be included in
the body of the AUP. The entire SOP need not be re-written nor re-entered into the body of the AUP.

Who writes an SOP?

An SOP is usually written by the person who routinely performs the work. This can be a manager,
technician, researcher, or graduate student who is most familiar with the procedures. The SOP can also
be written by a team of people familiar with the work. Consultation with other animal users,
collaborators, veterinarian, biosafety specialist or other experts is strongly encouraged.
How is the SOP submitted, reviewed and approved?

All SOPs must be reviewed by the University Veterinarian. This is best done prior to sending the SOP to
the ACC for approval, as the veterinarian can help ensure the procedures are safe and humane.
Submitting the SOP to the veterinarian before submitting to the ACC can help speed the process of
approval. The University Veterinarian can be contacted at any time to help in developing the SOP.

All Animal Care and Use SOPs must be approved by the ACC before the work can be started. These
SOPs are submitted to the ACC Coordinator through the Office of Research two weeks prior to the ACC’s
meetings. Once reviewed, the Office of Research will send notification on the status of approval after
the meeting. If any changes are needed, these are submitted to the ACC Coordinator and forwarded to
a subcommittee, which includes the University Veterinarian, for review. Once approved, the SOPs are
assigned a number and added to the Officer of Research SOP data base.

Approved SOPs can be accessed through the Office of Research. Copies of approved SOPs must be
located within the appropriate facility and readily available to persons performing the procedures.

The SOPs must be reviewed by the ACC every 3 years to ensure the procedures meet current practice
and standards. This process of review starts with notification to the author, manager, or principle
investigator by the ACC Coordinator. The SOP must be modified and updated at anytime if there needs
to be a change of procedure. Once reviewed and edited, the SOP is re-submitted to the ACC for
approval through the Office of Research.

How to write the SOP using the template provided:

The following check list will help the Office of Research categorize your SOP.

Facility Category: ___ LUACF ___ Aquatics ___ Wildlife ___other (specify: _____________ )

Title: A brief, one sentence, description of the procedure and species covered by the SOP.

e.g. Injection techniques for the Rat

Species: Please give the familiar name of the species (e.g. rat) or group of species (e.g.
rodents), as well as the scientific name (e.g. rattus norwigicus) when appropriate. This is not
required if the species is adequately described in the title. If the title is very general (e.g.
Injection techniques in fish), then a brief list of applicable species should be included here (e.g.
Fathead Minnow, Salmonids).

1. Purpose: A brief description, one or two sentences, of what the SOP is intended to cover.
2. Responsibility: who will carry out the procedure and/or who is responsible to ensure the
SOP is carried out as written. (e.g. Animal Care Technician, Facilities Manger, Veterinarian)
3. Minimum Qualifications/Training Required: a list of minimum qualifications or training
required to carry out the SOP. You do not need to include training required to access the
facility, unless it is applicable to the SOP (e.g. CCAC modules 1 to 12, Facility Orientation,
WHIMS, etc.)
 Example:

1.1. Two years experience in handling rodents

1.2. Course in basic surgery techniques
1.3. Course in anesthesia of rodents

4. Materials: a detailed list of the supplies you will need to carry out this SOP. Details, such as
manufacturer, make and model, are helpful for reordering supplies. You are encouraged to
include as much detail as possible so that there is a consistency in the type of supplies used.
In some cases, this can help clarify any potential issues for the ACC (e.g. cage or trap type
and size) and speed up the approval process.

Example:

1.1. Povidone-Iodine disinfectant (e.g. Betadine Surgical Scrub)

1.2. Eye lubricant (e.g. Lacri-lube by Allergan)

List any Personal Protective Equipment (PPE) required in the Materials section. Please contact
the University Biosafety Officer or Facilities Manager for guidance on PPE requirements.

Example:

1.6 Gloves
1.7 Lab coat
1.8 Face mask

5. Procedure: This is a detailed step-by-step list of how the procedure will be carried out. It
should be in chronological order, clear and concise. Include the maximum frequency of
procedures when necessary (e.g. multiple blood samples). It should also state any
emergency procedures or precautions that should be taken (e.g. If rat stops breathing,
perform CPR). Include procedures for safe waste disposal, if applicable (e.g. Place
uncapped needles in sharps container).

Avoid the use of passive voice.

Passive voice: The incision should not be made outside of the surgically clean area.

Active voice: Make the incision in the surgically clean area.

6. References: If you used an SOP from another institution or organization, please reference
its source here. Make sure you have obtained permission to use this SOP from the original
author. You can also list other references that are relevant to the SOP.

Review/Approval: This is for Office of Research use to ensure the proper procedures for
approval have been carried out.