Form 10-1302 IACUC Annual Review Form

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

OMB Control No. 1024-0265
Expiration Date: 08/31/2019

ANNUAL REVIEW FORM
INSTITUTIONAL ANIMAL CARE AND USE COMMITTEE
Natural Resources Stewardship and Science Directorate
Biological Resources Division
1201 Oakridge Drive, Suite 200
Fort Collins, CO 80525
Telephone: (970) 267-7237 or Email: [email protected]

Date of Submission:
NPS IACUC Project Name:

Ex: IMR_ROMO_Smith_Birds_2019.A3

Enter xplantio and tepro sedforcmpletion.

Principal Investigator (PI) Name:

PI Email:
PI Phone Number:

Original Approval Date:

What is the expected end date of your project?

No

Has the Principal Investigator (PI) for this project changed?

Provide a summary of your activities from the past year. Include adverse events, unanticipated morbidity or mortality, the cause(s), if known,
how these problems were resolved, and how these will be prevented in future activities.

No

Are changes to the IACUC approved protocol planned in the next year?

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

OMB Control No. 1024-0265
Expiration Date: 08/31/2019

Has the NPS Contact changed?

Yes

NPS Contact:

NPS Unit

Email:

Phone Number:
Has the Attending Veterinarian or DelegatedVeterinarian changed?

Yes

Name of Veterinarian (as appears on licensure)

State of Licensure

Email:

Phone Number:

Have any other changes in personnel occurred? If you need more space to add personnel, please attach additional information.

Yes

First and Last Name

Role on Project

Relevant Education, Training, & Species Experience

First and Last Name

Role on Project

Relevant Education, Training, & Species Experience

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

Common Name

Scientific
Name

If you need more space to add species please attach additional information.

2

# Approved

# Used

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

No

OMB Control No. 1024-0265
Expiration Date: 08/31/2019

Do you have any Audiovisual Records?

Assurance Statement
The information in this Annual Review 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 training 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 training 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
We are collecting this information subject to the Paperwork Reduction Act (44 U.S.C. 3501) for the purposes of reviewing activities related to the
care and use of animals and to approve all research, teaching, and training activities involving vertebrate animals on NPS managed lands and
territories. Your response to this request is mandatory in order to conduct research involving vertebrate animals on NPS managed lands and
territories. A Federal agency may not conduct or sponsor, and you are 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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