Form 10-1303 IACUC Concurrence Form

NPS Form 10-1303 (03/2016)
National Park Service

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

CONCURRENCE 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:

Submission Information:
Principal Investigator's (PI) Name:
PI's Email:
PI's Phone Number:

NPS Contact:

NPS Unit:

Phone Number:

Email:

Primary IACUC Information:
Institution Name:
Institution's USDA Research Registration (optional):
IACUC Chair or Administrator Name, Phone, and Email:

Protocol Reference Number:

Protocol Expiration Date:

Protocol Approval Date:

I have attached a copy of the complete protocol and valid approval notice.

Performance Site Information:
How many separate NPS units are associated with this submission? 1

Park Name

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NPS Form 10-1303 (03/2016)
National Park Service

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

Study Information (Select ONE):
The attached IACUC protocol is COMPLETE for all vertebrate animal activities PLANNED TO OCCUR ON NPS UNITS ONLY. The protocol
contains complete information for all personnel working with animals with their relevant experience and training, species and number
proposed to be captured and handled, and complete descriptions of all activities to be conducted on vertebrate animals. If any procedures in
the planned activities may cause more than momentary or slight pain and distress to the animals, a search for alternatives to these
procedures is included within this protocol or will be attached for NPS IACUC review.

The attached IACUC protocol outlines activities which are planned to occur ON NPS units as well as OUTSIDE of NPS units. Those
activities involving vertebrate animals planned to occur ON NPS units pertinent for the NPS IACUC to review have had those sections of text
highlighted throughout the submitted protocol.

Additional vertebrate animal activities planned to be carried out on NPS units ARE NOT INCLUDED in the attached IACUC protocol.
Detailed information on these vertebrate animal activities for review are provided here:

Enter additional information for NPS IACUC review.

Assurance Statement:
By submitting this document to the NPS IACUC, I verify and acknowledge that:
All information described here is complete and accurate;
All personnel will be adequately trained or supervised in proper care and use of animals;
No change to the animal use protocol will be instituted without prior review and approval by the primary IACUC and NPS IACUC;

All individuals working under this Assurance will comply with the Animal Welfare Act (AWA) Regulations and Standards and the Interagency
Research Animal Committee (IRAC) United States Government Principles;

All field research will be carried out in accordance with the applicable principles outlined in:
Guidelines to the Use of Wild Birds in Research

Guidelines of the American Society of Mammalogists
Guidelines for Use of Live Amphibians and Reptiles in Field and Laboratory Research
Guidelines for the Use of Fishes in Research
American Veterinary Medical Association Guidelines for the Euthanasia of Animals

All work proposed herein is designed in the attempt to minimize distress and pain to the animals; does not unnecessarily duplicate previous
experimentation; and non-animal alternatives have been considered;
All euthanasia methods outlined for vertebrate species will be conducted according to the current AVMA Panel Guidelines on Euthansia
Methods.

Enter Full Name as Signature:
Date:
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NPS Form 10-1303 (03/2016)
National Park Service

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

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 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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