NMMTB Tissue Request Form

National Marine Mammal Tissue Bank
Tissue Request Form
Principle Investigator(s):___________________________________________________
Investigator(s) Title:______________________________________________________
Affiliated Institution(s):___________________________________________________
Address:________________________________________________________________
________________________________________________________________
E-mail:_________________________________Phone:__________________________

Requirements for Samples:
Total Number of Samples Requested:_________
Total Number of Animals Requested:_________
Total Number of Each Sample Type Requested: Liver _____
Kidney _____
Other

Blubber _____
Blood

_____

_____

List other type:_______________
Title of Project:

_______________________________________________________
_______________________________________________________

Research Location:_______________________________________________________
_______________________________________________________
Type of Research: ________________________________________________________
________________________________________________________
Estimated Date of Completion: ______________________________________________

Attach the following items:
1)

2)
3)
4)
5)

A description of the proposed research including a justification as to the use of the
banked tissues and how this is consistent with the goals of the NMMTB and the
MMHSRP;
Copy of the scientific research permit;
Verification that funding is available to conduct the research;
Table 1 filled out completely;
A signed copy of the National Marine Mammal Tissue Bank Agreement Form

OMB Control No. 0648-0468, Expiration Date: 01/31/2015

Table 1. Individual Sample Information for Tissues Requested from the National Marine Mammal Tissue Bank.

Field ID

NMMTB
Storage ID

ex. MMES2004100SC NM10L101C

Species

Common
Name

Tursiops truncatus

Bottlenose dolphin

Tissue
Year
Requested Collected Sex
Liver

2004

F

Age
Class
Adult

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

OMB Control No. 0648-0468, Expiration Date: 01/31/2015

Pregnant or
# of samples
Lactating (4-6g ea.) requested
No

1

National Marine Mammal Tissue Bank
Agreement Form
I, _______________________, agree to the following conditions upon acceptance of my
proposed research on tissues taken from the National Marine Mammal Tissue Bank:
1)

Research/findings based on use of the banked tissue will be reported to the National
Marine Mammal Tissue Bank, Marine Mammal Health and Stranding Response Program
Manager, and the specimen contributor;

2)

Tissue specimen samples that are used/released for genetic analyses (DNA sequencing)
are required to archive sequences in the National Center for Biotechnology Information’s
GenBank. Sequence accessions in GenBank should document the source, citing the
NMMTB Field ID number that identifies the animal;

3)

Credit and acknowledgment will be given to U.S. Fish and Wildlife Service (USFWS),
U.S. Geological Survey (USGS), National Marine Fisheries Service (NMFS), National
Institute of Standards and Technology (NIST), the Mineral Management Service (MMS),
the National Marine Mammal Tissue Bank (NMMTB), and the specimen collector for
use of the banked tissues. I shall insert the following acknowledgment in all publications,
abstracts or presentations based on research using the banked tissue:
The specimens used in this study were collected by the contributor and provided by the
National Marine Mammal Tissue Bank, which is maintained in the National
Biomonitoring Specimen Bank at NIST, and which is operated under the direction of
NMFS with the collaboration of USGS, USFWS, MMS, and NIST through the Marine
Mammal Health and Stranding Response Program (and the Alaska Marine Mammal
Tissue Archival Project [if the samples are from Alaska]).

_________________________________
Signature

_________________
Date

_________________________________
_________________________________
Affiliation

OMB Control No. 0648-0468, Expiration Date: 01/31/2015