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, 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 10 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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