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pdfNPS Form 10-1301 (03/2016)
National Park Service
OMB Control No. 1024-0265
Expiration Date: XX/XX/XXXX
GENERAL SUBMISSION (GS) FORM
INSTITUTIONAL ANIMAL CARE AND USE COMMITTEE
Natural Resources Stewardship and Science Directorate
Biological Resource Management Division
1201 Oakridge Drive, Suite 200
Fort Collins, CO 80525
Telephone: (970) 225-3566 or Email: [email protected]
Check List
I have entered all relevant information in this GS Form. (The GS form is a standalone
document. The NPS IACUC will not review study plans or scientific proposals to answer questions left blank on the GS form. Supporting
materials may be attached to the GS form, but they cannot substitute for material that must be answered on the GS form.
I have reviewed the Animal Welfare Act , its regulations and standards, and have designed the study using the three Rs of reduction,
refinement, and replacement to minimize animal pain and distress.
I have followed, to the extent practicable, the relevant recommendations and guidelines developed by professional societies such as:
Guidelines of the American Society of Mammalogists
Guidelines to the Use of Wild Birds in Research
Guidelines for Use of Live Amphibians and Reptiles in Field and Laboratory Research
Guidelines for the Use of Fishes in Research, and
American Veterinary Medical Association Guidelines for the Euthanasia of Animals
and have referenced those specific guidelines in this GS Form.
I have digitally signed this GS form prior to submission to the NPS IACUC.
If you are unsure of what is required to complete this form, please visit the NPS IACUC web page, or contact the IACUC Administrator
([email protected]; 970-267-2162).
SAVE for ATTACHMENT
PRINT FORM
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CLEAR FORM
NPS Form 10-1301 (03/2016)
National Park Service
OMB Control No. 1024-0265
Expiration Date: XX/XX/XXXX
ASSURANCE OF ANIMAL CARE FORM
Project Title:
Enter your project's title
Park Units Involved in Study:
Enter all NPS Park units involved in the study
Name(s) of Funding Source(s):
How many Funding Sources are there?
Enter Acronym
1
Spell-out acronym
Approximate Proposed Starting Date:
Enter your project's approximate start date
Completion Date:
Enter your project's expected completion date
Is this an ongoing project?
No
I. PERSONNEL
1
Email Address:
2
Phone Number:
NPS Unit:
NPS Contact:
Email Address:
3
NPS Unit:
NPS Contact:
Phone Number:
NPS Unit:
NPS Contact:
Email Address:
Phone Number:
Principal Investigator's Name:
Email Address:
Phone Number:
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NPS Form 10-1301 (03/2016)
National Park Service
OMB Control No. 1024-0265
Expiration Date: XX/XX/XXXX
Will the Principal Investigator be on site for the entire project?
Yes
Attending Veterinarian?
All projects must have an official Attending Veterinarian (AV). The AV is traditionally the individual with whom the project PIs consult in the
planning of activities involving the use of vertebrate animals. The NPS IACUC Attending Veterinarian, Tracy Thompson, DVM, is the official,
default AV for all submissions. If additional veterinarians will be delegated to consult on these activities, please list below.
I have read and understand the above statement.
0
How many delegated veterinarians are there?
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NPS Form 10-1301 (03/2016)
National Park Service
OMB Control No. 1024-0265
Expiration Date: XX/XX/XXXX
Personnel Qualifications:
0
How many personnel are involved in the animal component of this project?
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NPS Form 10-1301 (03/2016)
National Park Service
OMB Control No. 1024-0265
Expiration Date: XX/XX/XXXX
Purpose and Intent of Study:
How would you explain to a non-scientist, the specific objective(s) of your study?
Does this study duplicate previous research?
No
Study Classification:
Field Research
Combination
Captive Research
Combination of Field and Captive Research
Specific Study Areas:
Animal Housing:
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NPS Form 10-1301 (03/2016)
National Park Service
OMB Control No. 1024-0265
Expiration Date: XX/XX/XXXX
II. USE OF VERTEBRATE ANIMALS AND PROJECT DETAILS
Scientific Name
No
Common Name
# to be
# to be
Used (Year Used (Year
1)
2)
Is additional space needed for more study animals?
Do you have any OPPORTUNISTIC or NON-TARGET ANIMALS in your study?
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No
# to be
Used (Year
3)
NPS Form 10-1301 (03/2016)
National Park Service
OMB Control No. 1024-0265
Expiration Date: XX/XX/XXXX
What is the rationale for the use of animals?
What is the appropriateness of species to be used?
Provide a detailed justification for the number of animals to be used:
THE U.S.D.A Annual Report requires the NPS IACUC to report the number of animals used by or under control in each
of the following categories:
B) Numbers of animals being bred, conditioned, or held for use in teaching, testing, experiments, research, or surgery but not yet used for such
purposes.
C) Number of animals upon which teaching, research, experiments, or tests were conducted involving no pain, distress, or use of pain-relieving drugs.
D) Number of animals upon which experiments, teaching, research, surgery, or tests were conducted involving accompanying pain or distress to the
animals and for which appropriate anesthetic, analgesic, or tranquilizing drugs were used.
E) Number of animals upon which teaching experiments, research, surgery, or tests were conducted involving accompanying pain or distress to the
animals and for which the use of appropriate anesthetic, analgesic, or tranquilizing drugs would have adversely affected the procedures, results, or
interpretation of the teaching, research, experiments, surgery, or tests (An explanation of the procedures producing pain or distress in these animals
and the reason such drugs were not used must be attached to this report.
Categories will be assigned by the NPS IACUC based on the highest anticipated pain/distress level found in the description of proposed procedures.
The category assignment is recorded on the approval letter sent to the PI. Category D or E requires a search for alternatives to those procedures that
may cause pain or distress.
I have read and understand the above USDA APHIS AC Categories.
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NPS Form 10-1301 (03/2016)
National Park Service
No
OMB Control No. 1024-0265
Expiration Date: XX/XX/XXXX
Do any proposed procedures cause more than momentary or slight pain or distress?
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NPS Form 10-1301 (03/2016)
National Park Service
OMB Control No. 1024-0265
Expiration Date: XX/XX/XXXX
Animal Use Procedures:
No
Will WILDLIFE CAPTURE BE CONDUCTED (LIVE CAPTURE OR KILL TRAPPING)?
No
Will any ANIMALS BE TRANSPORTED?
No
Will any PHYSICAL RESTRAINT be used after capture?
No
Will any CLEANING PROCEDURES of equipment be done?
No
Will PERSONAL PROTECTIVE EQUIPMENT (PPE) be used?
Please refer to: Compendium of Veterinary Standard Precautions
No
No
and the
Will there be MONITORING OF PHYSIOLOGICAL VITAL SIGNS?
Will there be any MARKING OR TAGGING?
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Safe Work Practices Field Guide.
NPS Form 10-1301 (03/2016)
National Park Service
No
OMB Control No. 1024-0265
Expiration Date: XX/XX/XXXX
Will any BLOOD SAMPLES be taken?
No
Will any URINE OR FECES SAMPLES be taken?
No
Will there be any OTHER BODY FLUID OR TISSUE SAMPLING?
No
Is this a BEHAVORIAL OR OBSERVATIONAL STUDY (WITHOUT PROLONGED RESTRAINT OR
NOXIOUS STIMULI)?
Will there be BEHAVIORAL OR OBSERVATIONAL TESTING (WITH PROLONGED RESTRAINT OR NOXIOUS
STIMULI)?
No
No
Will any SPECIAL DIETS be utilized?
No
Will there be any FOOD AND/OR WATER DEPRIVATION?
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NPS Form 10-1301 (03/2016)
National Park Service
OMB Control No. 1024-0265
Expiration Date: XX/XX/XXXX
No
Will there be any INDWELLING CATHETERS OR IMPLANTS?
No
Will PARALYTICS be administered?
No
Will any ANESTHETICS be administered?
No
Will any ANALGESICS be administered?
No
Will CONTROLLED AND/OR PRESCRIPTION PHARMACEUTICALS be utilized?
No
Will any DRUGS, TOXINS, REAGENTS, CELLS, ETC. (OTHER THAN ANALGESICS, ANESTHETICS,
OR PARALYTICS) be administered?
No
Will DEATH BE USED AS AN ENDPOINT?
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NPS Form 10-1301 (03/2016)
National Park Service
No
OMB Control No. 1024-0265
Expiration Date: XX/XX/XXXX
Will any OTHER procedures be utilized that the NPS IACUC should be aware of?
III. TYPE, FREQUENCY, AND TREATMENT OF INJURIES
Describe the most likely forms of injuries to research animals, how frequent injury(ies) is(are) expected to occur, and planned procedures for injured
animals (treatment or euthanasia).
IV. EUTHANASIA AND DISPOSITION
All methods of euthanasia must follow the American Veterinary Medical Association Guidelines for the Euthanasia of Animals. Any deviations must be
scientifically justified.
Describe the method of euthanasia planned:
Describe the method used to ensure the animal will not revive:
Disposition of remains:
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NPS Form 10-1301 (03/2016)
National Park Service
OMB Control No. 1024-0265
Expiration Date: XX/XX/XXXX
V. Animal Surgery Information
Yes
Is there surgery planned for this study?
Scientific Name
Common Name
# to be Used
Survival /
Non-Survival
Major/Minor
Scientific Name
Common Name
# to be Used
Survival /
Non-Survival
Major/Minor
Scientific Name
Common Name
# to be Used
Survival /
Non-Survival
Major/Minor
Scientific Name
Common Name
# to be Used
Survival /
Non-Survival
Major/Minor
Scientific Name
Common Name
# to be Used
Survival /
Non-Survival
Major/Minor
No
Will additional animals undergo surgery?
Pre-operative Procedures and Care:
No
A) Will unhealthy animals be exempted from surgery?
B) Which individuals are responsible for evaluating pre-operative health status of animals?
C) Which pre-operative procedures and care will be utilized?
D) Provide a description of the area where the surgery will be performed, how it is prepared before each surgery, how surgical instruments are
prepared, and how individuals responsible for surgery prepare themselves.
Anesthetic Procedures:
A) What anesthetic procedures will be used (name, route, dose, frequency, and duration)?
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NPS Form 10-1301 (03/2016)
National Park Service
OMB Control No. 1024-0265
Expiration Date: XX/XX/XXXX
B) Which individual(s) will be performing and monitoring anesthesia?
Surgical Procedures:
A) Describe the surgical procedures to be performed.
B) How will aseptic conditions be maintained throughout the surgical procedures?
C) Who will be performing surgical procedures?
Post-operative Procedures and Care
A) Will there be post-operative monitoring of animals?
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NPS Form 10-1301 (03/2016)
National Park Service
OMB Control No. 1024-0265
Expiration Date: XX/XX/XXXX
Yes
B) Will post-operative analgesics be used?
Please provide the name, dose, route, and frequency of the analgesics used.
C) Describe all post-operative procedures and care.
Yes
D) Will there be use of any antibiotics or other therapeutic drugs?
Please provide name, dose, route, and frequency.
Yes
E) Does the surgical procedure induce disease, functional alteration, etc.?
Please provide scientific justification for inducing such conditions.
Multiple Surgeries:
Yes
A) Will animals be subjected to more than one (1) survival surgery?
Please provide scientific justification for why more than one survival surgery is needed.
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NPS Form 10-1301 (03/2016)
National Park Service
OMB Control No. 1024-0265
Expiration Date: XX/XX/XXXX
Permits:
Permit Type
Permit Number
Expiration Date
Permit Type
Permit Number
Expiration Date
Permit Type
Permit Number
Expiration Date
Permit Type
Permit Number
Expiration Date
Permit Type
Permit Number
Expiration Date
V. AUDIOVISUAL RECORD
No
Do you have an Audiovisual Record for your submission?
VI. LITERATURE CITATIONS
Do you have additional literature to cite for this project?
No
Assurance Statement
The information in this general submission Form is an accurate description of the animal care and use
protocol(s) to be used in the described project. All people handling animals in this project have been, or will
be, properly trained in the methods, protocols, and equipment described in this submission form. All
individuals working under this project will comply with the requirements of the Animal Welfare Act, its
Regulations and Standards, and the Interagency Research Animal Committee U.S. Government Principles.
All work proposed herein is designed to minimize pain and distress to the animals, does not unnecessarily
duplicate previous experimentation, and cannot be reasonably conducted using non-animal alternatives.
Please type your full name as your signature:
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NPS Form 10-1301 (03/2016)
National Park Service
OMB Control No. 1024-0265
Expiration Date: XX/XX/XXXX
THIS PAGE INTENTIONALLY LEFT BLANK
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NPS Form 10-1301 (03/2016)
National Park Service
OMB Control No. 1024-0265
Expiration Date: XX/XX/XXXX
THIS PAGE INTENTIONALLY LEFT BLANK
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NPS Form 10-1301 (03/2016)
National Park Service
OMB Control No. 1024-0265
Expiration Date: XX/XX/XXXX
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NPS Form 10-1301 (03/2016)
National Park Service
OMB Control No. 1024-0265
Expiration Date: XX/XX/XXXX
NOTICES
Privacy Act Statement
General: This information is provided pursuant to Public Law 93-579, Privacy Act of 1974, for individuals completing this form.
Authority: The authority to collect information on the attached form is derived from the 7 U.S.C. Chapter 54, Transportation, Sale, and Handling of
Certain Animals.
Purposes and Uses: The information is being collected for the purpose of reviewing activities related to the care and use of animals and to
approve all research, teaching, and exhibition activities involving vertebrate animals on NPS managed lands and territories. . Information from the
application may be transferred to appropriate Federal, State, and local agencies, when relevant to civil, criminal or regulatory investigations or
prosecutions.
Disclosure: Providing your information is voluntary, however, failure to provide the requested information may impede the National Park Service the
review of activities related to the care and use of animals and to approve, all research, teaching, and exhibition activities involving vertebrate animals
on NPS managed lands and territories. . If you provide the information, please be advised that the U.S. Criminal Code, Title 18 U.S.C. 1001, provides
that knowingly falsifying or concealing a material fact is a felony that may result in fines of up to $10,000 or 5 years in prison, or both. Deliberately and
materially making false or fraudulent statements on this form will be grounds for not approving your submission.
Paperwork Reduction Act Statement
This information collection is subject to the Paperwork Reduction Act (44 U.S.C. 3501) and The National Park Service Organic Act (16 U.S.C. 1a-7).
The information in this form will be used by National Park Service Institutional Animal Care and Use Committee (NPS IACUC) for the purposes of
reviewing activities related to the care and use of animals and to approve all research, teaching, activities involving vertebrate animals on NPS
managed lands and territories. No action may be taken against you for refusing to supply the information requested, however this complete form must
be submitted, reviewed, and approved before any related activities can be performed. 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.
Estimated Burden Statement
The time to complete this form is estimated to be 3 hours per response. You may send comments concerning the burden estimate or any aspect of
this information collection to: Information Collection Clearance Officer, National Park Service, 12201 Sunrise Valley Drive, MS-242, Reston, VA
20192.
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| File Type | application/pdf |
| Author | Smith, Aaron David |
| File Modified | 2016-03-28 |
| File Created | 2016-01-12 |