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

List other type:

Blubber Blood

Title of Project:

Research Location:

Type of Research:

Estimated Date of Completion:

Attach the following items:

1. 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;

2. Copy of the scientific research permit;

3. Verification that funding is available to conduct the research;

4. Table 1 filled out completely;

5. A signed copy of the National Marine Mammal Tissue Bank Agreement Form

Expiration Date: 01/31/2015

OMB Control No. 0648-0468,

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

	Field ID	NMMTB Storage ID	Species	Common Name	Tissue Requested	Year Collected	Sex	Age Class	Pregnant or Lactating	# of samples (4-6g ea.) requested
ex.	MMES2004100SC	NM10L101C	Tursiops truncatus	Bottlenose dolphin	Liver	2004	F	Adult	No	1
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

Expiration Date: 01/31/2015

OMB Control No. 0648-0468,

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

Affilia

tion

Privacy Act Statement

Authority: The collection of this information is authorized under 5 U.S.C. § 301, Departmental regulations and 15 U.S.C. 1512, Powers and duties of Department.

Purpose: As part of the signed Data Submission Agreements, data providers’ and principal investigators’ name, email, and physical address are recorded as part of the metadata for the submitted data set, and for contact purposes when needed. Information on the data providers and principal investigators is necessary in order for a system administrator to contact an individual in the event of a problem during the archiving process. Such information is also necessary to identify the sources of data, especially for properly crediting the providers and principal investigators on the individual holdings in the archive.

Name, email and address may be collected for those requesting data, so that they may open an account through which to receive the data.

Routine Uses: Disclosure of this information is permitted under the Privacy Act of 1974 (5 U.S.C. Section 552a) to be shared among Department staff for work-related purposes. The Department will use this information to contact data providers in the event of a problem during the archiving process, and to properly credit providers and principal investigators on the individual holdings in the archive. Disclosure of this information is also subject to all of the published routine uses as identified in the Privacy Act System of Records Notice COMMERCE/NOAA-11, Contact Information for Members of the Public Requesting or Providing Information Related to NOAA’s Mission.

Disclosure: Furnishing this information is voluntary; however, failure to provide accurate information may delay or prevent required contacts regarding archiving problems, proper archiving, and provision of data.