Form 10-1304 IACUC Field Study Form

NPS Form 10-1304 (03/2016)
National Park Service

OMB Control No. 1024-0265
Expiration Date: 08/31/2016

FIELD STUDY 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:
Principal Investigator (PI) Name:

PI Email:
PI Phone Number:

NPS unit(s) associated with this submission:

Dates Planned:

NPS Unit:

NPS Contact

Phone Number:

Email:

To see an explanation/example for each field, hover over the

Example

How would you explain to a non-scientist, the specific objective(s) of your study?

Activities and Procedures Planned:

Example

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NPS Form 10-1304 (03/2016)
National Park Service

OMB Control No. 1024-0265
Expiration Date: 08/31/2016

Species and numbers expected to be captured:

Example

What capture methods will be used, how will animals be handled, and for how long?

Example

What Personal Protective Equipment (PPE) will be used? What cleaning procedures of equipment will be done?

Please refer to: Compendium of Veterinary Standard Precautions and the Safe Work Practices Field Guide.

Who will be involved in handling animals? For staff please provide their first and last name, relevant education, training,
and species/procedure experience. For trainees or students please provide type of trainng and supervision for procedures.

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Example

NPS Form 10-1304 (03/2016)
National Park Service

OMB Control No. 1024-0265
Expiration Date: 08/31/2016

Describe the method of euthanasia planned, including a secondary method to ensure animal will not revive:

Even if you do not expect to have to euthanize animals during your work, a method of euthanasia must be listed in cases of emergency. Also
include who will be responsible for euthanization and what their training/experience is.
All methods of euthanasia must follow the American Veterinary Medical Association Guidelines for the Euthanasia of Animals.
Any deviations must be scientifically justified.

REINITIATION NOTICE FOR IACUC REVIEW OF PROJECTS DESIGNATED AS FIELD STUDY

This concludes formal review of the submitted animal use activities. Reinitiation of formal review is required where information reveals (1) effects of the
submitted activities may affect listed species in a manner or to an extent not considered in this submission; (2) the activities are modified in a manner tha
causes an effect to the listed species not considered in this decision; or (3) a new species is listed for use; activities must cease pending reinitiation. IF
UNANTICIPATED MORBIDITY OR MORTALITY OF STUDY ANIMALS OCCURS, PLEASE CONTACT THE NPS IACUC AS SOON AS POSSIBLE.

Enter Full Name as 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 1 hour 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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