Form 10-1301A IACUC Amendment Form

NPS Form 10-1301A (03/2016)
National Park Service

OMB Control No. 1024-0265
Expiration Date: XX/XX/XXXX

AMENDMENT 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]
Date:
Principal Investigator (PI) Name:
PI Email:

PI Phone Number:
Date:
Any questions as to whether or not your proposed protocol change requires an amendment, please consult the NPS IACUC. ANIMAL ACTIVITIES
SHOULD NOT BE CONDUCTED UNTIL APPROVAL OF THIS AMENDMENT IS RECEIVED.
Yes

Are the objectives or intent of the study changing?

Yes

Will new procedures be performed?

Yes

Are changes to approved procedures planned?

Yes, Procedures

Will changes to procedures be made that may increase the potential for more than momentary or slight pain or distress to
the animals? OR Is a non-survival surgical procedure being changed to a survival surgical procedure?

If analgesics/sedation/anesthetics will be used, include the name, route, dosage, frequency, duration, monitoring, and recovery. If anesthesia or other
pain relieving methods are not planned, provide justification for withholding them.
For survival surgery additions, also provide pre, peri, and postoperative monitoring information or attach a complete description.

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CLEAR FORM

NPS Form 10-1301A (03/2016)
National Park Service

OMB Control No. 1024-0265
Expiration Date: XX/XX/XXXX

No

Will new species be added for study or as opportunistic or non-target animals?

No

Are changes planned to anesthesia drugs for the approved procedures?

No

Will euthanasia method be changed?

No

Will the number of approved species be increased? (10% or more when > 50 animals originally approved or by 20% or more for 50
or fewer originally approved)

No

Will the principal investigator remain the same?

Name of New Principal Investigator:
Date:
No

Phone Number:
Will any other changes not listed above be made to the approved project?

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NPS Form 10-1301A (03/2016)
National Park Service

OMB Control No. 1024-0265
Expiration Date: XX/XX/XXXX

ALTERNATIVE SEARCH FOR NEW OR MODIFIED PROCEDURES THAT MAY CAUSE MORE THAN MOMENTARY OR SLIGHT PAIN AND
DISTRESS
Yes

Has the NPS AV or another wildlife veterinarian been consulted in developing these procedures?
Please provide the date of this consult:
List these procedures:

Alternatives to Painful Procedures Search

Databases Searched (2 at a minimum):
Please type your full name as your signature

Agricola
Altweb
EBSCO
Google Scholar
JStore
Other
Science Direct
Web of Science (Biosis,...)

If OTHER is selected, enter name here:
Date Search Conducted:

Years Covered by Search:

Search Strategy:

Please describe what alternatives were considered and discuss, or explain, why these alternatives cannot be used.

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NPS Form 10-1301A (03/2016)
National Park Service

OMB Control No. 1024-0265
Expiration Date: XX/XX/XXXX

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
Date:

NOTICES
Privacy Act Statement
General: This information is provided pursuant to Public Law 93-579 (Privacy Act of 1974),
December 21, 1984, for individuals completing this application.
Authority: The authority to collect information on the attached form is derived from Title 31,
United States Code, Section 7701.
Purposes and Uses: The information being collected to allow the park manager to make a value
judgment on whether or not to allow the requested use. Information from the application may be
transferred to appropriate Federal, State, and local agencies, when relevant to civil, criminal or
regulatory investigations or prosecutions.
Effects of Nondisclosure: It is in your best interest to answer all of the questions. 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 granting you a Special Use Permit
Information Regarding Disclosure of Your Social Security Number Under Public Law 93-579 Section
7(b): Your Social Security Number (SSN) is needed to identify records unique to you. Applicants
are required to provide their social security or taxpayer identification number for activities
subject to collection of fees and charges by the National Park Service (31 U.S.C. 7701). Although
disclosure of your SSN is not mandatory, failure to disclose your SSN may prevent or delay the
processing of your application. The authority for soliciting and verifying your SSN is Executive
Order 9397. The information gathered through the use of the SSN will be used only as necessary for
processing this application and will be carried out in accordance with established regulations and
published notices of system of records.
Paperwork Reduction Act Statement
We are collecting this information subject to the Paperwork Reduction Act (44 U.S.C. 3501) to
provide the park managers the information needed to decide whether or not to allow the requested
use. All applicable parts of the form must be completed in order for your request to be
considered. You are not required to respond to this or any other Federal agency-sponsored
information collection unless it displays a currently valid OMB control number.
Estimated Burden Statement
Public reporting burden for this form is estimated to average 15 minutes per response including the time it takes to read, gather and maintain data,
review instructions and complete the form. Direct comments regarding this burden estimate, or any aspects of this form, to the Information Collection
Clearance Officer, National Park Service, 12201 Sunrise Valley Drive, Mail Stop 242, Reston, VA 20192.

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