Form 10-1302 IACUC Annual Review Form

NPS Form 10-1302 (03/2016)
National Park Service

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

ANNUAL REVIEW 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]
NPS IACUC Project Name:
Principal Investigator:
Anniversary Date:
Deadline for Submission:

Your Assurance of Animal Care is due for the one of two possible annual reviews. Return the review form by the anniversary date of your project
approval, or your approval will become inactive and all procedures must stop. Please carefully review the accompanying protocol to ensure that it is still
current. If minor modifications or changes have occurred, you may note them on this form. If major changes are anticipated, complete an Amendment
Form found on the NPS IACUC website by clicking the Project Review Tab, and submit along with this completed Annual Review Form by the above
deadline for submission. RETURN DOCUMENTS TO THE IACUC ADMINISTRATOR EVEN IF YOUR PROJECT IS COMPLETED.
Provide a summary of your activities from the past year and any deviations, if applicable.

If the activities were not conducted as approved, please describe the deviations including adverse events, unanticipated morbidility or mortality,
the cause(s), if known, how these problems were resolved, and how these will be prevented in future activities. If deviations in activities from
the approved submission will continue, please submit an Amendment Form to reflect the changes made to those activities.

Yes

Will your project remain active until the next IACUC approval anniversary?

No

Have any changes to the IACUC approved project been made in the last year?

SAVE for ATTACHMENT

PRINT FORM
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CLEAR FORM

NPS Form 10-1302 (03/2016)
National Park Service

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

Study, Opportunistic, and Non-Target Animal Numbers Used During Year Under Review
Study,
Opprtunistic, or
Non-Target

Scientific
Name

Common
Name

2

#
Approved

#
Used

Pain
Category

NPS Form 10-1302 (03/2016)
National Park Service

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

Personnel Changes
No

The Principal Investigator for this project has changed.

No

Have any NPS Contacts changed?

No

No

Has the Attending Veterinarian or DelegatedVeterinarian changed?

Have any other changes in personnel occurred? If more than 2, please attach additional information.

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NPS Form 10-1302 (03/2016)
National Park Service

No

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

Do you have any Audiovisual Records?

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, 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 15 minutes 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.
Please do not submit your form to this address.

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