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pdfNPS Form 10-1301 (03/2016)
National Park Service
OMB Control No. 1024-0265
Expiration Date: 06/30/2023
GENERAL SUBMISSION (GS) 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]
I. SUBMISSION INFORMATION
Date of Submission:
Principal Investigator (PI) Name:
PI Email:
PI Phone Number:
NPS Contact:
NPS Unit:
Email:
Phone Number:
NPS Contact:
NPS Unit:
Email:
Phone Number:
Project Title:
NPS Unit(s) Involved in Study:
Funding Source(s):
To see an explanation for a field, hover over the
No
buttons throughout the form.
Is this an ongoing project?
Approximate Start Date:
Approximate Completion Date:
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NPS Form 10-1301 (03/2016)
National Park Service
OMB Control No. 1024-0265
Expiration Date: 06/30/2023
I have entered all relevant information in this GS Form. (The GS form is a standalone document. The NPS IACUC will not review study
plans or scientific proposals to answer questions left blank on the GS form. Supporting materials may be attached to the GS form, but
they cannot substitute for material that must be answered on the GS form.
I have reviewed the Animal Welfare Act , its regulations and standards, and have designed the study using the three Rs of reduction,
refinement, and replacement to minimize animal pain and distress.
I have followed, to the extent practicalbe, the relevant recommendations and guidelines developed by professional societies, such as:
Guidelines of the American Society of Mammalogists
Guidelines to the Use of Wild Birds in Research
Guidelines for Use of Live Amphibians and Reptiles in Field and Laboratory Research
Guidelines for the Use of Fishes in Research, and
American Veterinary Medical Association Guidelines for the Euthanasia of Animals
and have referenced those specific guidelines in this GS Form.
I have digitally signed this GS form prior to submission to the NPS IACUC.
If you are unsure of what is required to complete this form, please visit the NPS IACUC webpage , or contact the IACUC Office at
[email protected].
II. PERSONNEL
Yes
Will the Principal Investigator be on site for the entire project?
Attending Veterinarian:
All projects must have an official Attending Veterinarian (AV). The AV is traditionally the individual with whom
the project PIs consult in the planning of activities involving the use of vertebrate animals. The NPS IACUC Attending Veterinarian is the
official, default AV for all submissions. If additional veterinarians will be delegated to consult on these activities, please list below.
I have read and understand the above statement.
0
How many delegated veterinarians are there?
No
Does this project include any TEACHING or TRAINING of students and/or staff?
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NPS Form 10-1301 (03/2016)
National Park Service
6 or more
OMB Control No. 1024-0265
Expiration Date: 06/30/2023
How many personnel are involved in the animal component of this project?
First and Last Name
Role on Project
Relevant Education, Training, & Species Experience
First and Last Name
Role on Project
Relevant Education, Training, & Species Experience
First and Last Name
Role on Project
Relevant Education, Training, & Species Experience
Role on Project
First and Last Name
Relevant Education, Training, & Species Experience
First and Last Name
Role on Project
Relevant Education, Training, & Species Experience
First and Last Name
Role on Project
Relevant Education, Training, & Species Experience
No
Is additional space needed for more personnel?
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NPS Form 10-1301 (03/2016)
National Park Service
OMB Control No. 1024-0265
Expiration Date: 06/30/2023
III. PROJECT DETAILS & USE OF VERTEBRATE ANIMALS
How would you explain to a non-scientist, the specific objective(s) of your study?
No
Does this study duplicate previous research?
Study Classification:
Field Research
Field Research
Combination of Field and Captive Research
Captive Research
Specific Study Areas:
Animal Housing:
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NPS Form 10-1301 (03/2016)
National Park Service
OMB Control No. 1024-0265
Expiration Date: 06/30/2023
Scientific Name
No
Common Name
# to be used # to be used # to be Used
(Year 1)
(Year 2)
(Year 3)
Is additional space needed for more study animals?
Do you have any OPPORTUNISTIC
Yes
Opprtunistic or
Non-Target
or NON-TARGET ANIMALS
Scientific Name
Common Name
in your study?
# to be used
(Year 1)
If you need more space to add species, please attach additional information.
Describe what handling, sampling, etc. will occur should an opportunistic or non-target animal be captured.
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# to be used
(Year 2)
# to be used
(Year 3)
NPS Form 10-1301 (03/2016)
National Park Service
OMB Control No. 1024-0265
Expiration Date: 06/30/2023
What is the rationale for the use of animals?
What is the appropriateness of species to be used?
Provide a detailed justification for the number of animals to be used:
The U.S. Government Principles state, "Unless the contrary is established, investigators should consider that procedures that
cause pain or distress in human beings may cause pain or distress in other animals."
USDA pain/distress categories (below) will be assigned by the NPS IACUC based on the highest anticipated pain/distress level
found in the description of proposed procedures:
B) Animals being bred, conditioned, or held for use in teaching, experiments, research, or surgery but not yet used for such
purposes
C) Animals upon which teaching, research, experiments, or tests were conducted involving no pain, distress, or use of
pain-relieving drugs
D) Animals upon which teaching experiments, research, surgery, or tests were conducted involving accompanying pain or
distress to the animals and for which the use of appropriate anesthetic, analgesic, or tranquilizing drugs were used
E) Animals upon which teaching experiments, research, surgery, or tests were conducted involving accompanying pain or
distress to the animals and for which the use of appropriate anesthetic, analgesic, or tranquilizing drugs would have adversely
affected the procedures, results, or interpretation of the teaching, research, experiments, surgery, or tests (An explanation of
the procedures producing pain or distress in these animals and the reason such drugs were not used must be attached to this
report).
I have read and understand the above USDA APHIS AC Categories.
Yes
Do any proposed procedures cause more than momentary or slight pain or distress?
List these procedures: You will need to complete a Literature Search on page 7of this form.
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NPS Form 10-1301 (03/2016)
National Park Service
No
OMB Control No. 1024-0265
Expiration Date: 06/30/2023
Has the NPS AV or another wildlife veterinarian been consulted in developing these procedures?
Note: The NPS AV can serve as the veterinary consult via review of this General Submission form.
If another veterinarian has been consulted, provide the date of this consult:
Alternatives to Painful Procedures Search
Provide a written description of the methods and sources used to determine that proposed procedures are the most refined possible and that
you have considered alternatives to procedures that may cause more than momentary or slight pain or distress to the animal.
For more information and tips for a successful search visit:
USDA Animal Welfare Information Center's Alternatives Literature Searching
Animal Welfare Information Center - IACUC - Wildlife
Agricola
Altweb
(Hold CTRL to select multiple choices) EBSCO
Google Scholar
JSTOR
Other
Science Direct
Web of Science (Biosis,...)
Databases Searched (2 at a minimum):
If OTHER is selected, enter name(s) here:
Date Search Conducted:
Search Strategy:
Years Covered by Search:
USDA Animal Welfare Information Center's Alternatives Literature Searching
Describe what alternatives were considered and discuss, or explain, why these alternatives cannot be used.
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NPS Form 10-1301 (03/2016)
National Park Service
OMB Control No. 1024-0265
Expiration Date: 06/30/2023
No
Will
WILDLIFE
Will
CAPTURE
WILDLIFE
BE
CAPTURE
CONDUCTED
BE
(LIVE
CONDUCTED
CAPTURE
(LIVE
OR
CAPTURE
KILL
OR
TRAPPING)?
KILL
TRAPPING)?
Animal Use Procedures:
No
Will WILDLIFE CAPTURE be conducted (live capture or kill trapping)?
No
Will any animals be TRANSPORTED?
No
Will any PHYSICAL RESTRAINT be used after capture?
No
What CLEANING PROCEDURES of equipment will be done?
No
What PERSONAL PROTECTIVE EQUIPMENT (PPE) will be used?
Please refer to: Compendium of Veterinary Standard Precautions and the Safe Work Practices Field Guide.
No
No
Will there be monitoring of PHYSIOLOGICAL VITAL SIGNS?
Will there be any MARKING or TAGGING of animals?
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NPS Form 10-1301 (03/2016)
National Park Service
No
OMB Control No. 1024-0265
Expiration Date: 06/30/2023
Will any BLOOD SAMPLES be taken?
No
Will any URINE or FECES SAMPLES be taken?
No
Will there be any OTHER BODY FLUID or TISSUE SAMPLING?
No
Will there be BEHAVIORAL or OBSERVATIONAL TESTING?
No
Will any SPECIAL DIETS be utilized?
No
Will there be any FOOD and/or WATER DEPRIVATION?
No
Will there be any INDWELLING CATHETERS or IMPLANTS?
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NPS Form 10-1301 (03/2016)
National Park Service
OMB Control No. 1024-0265
Expiration Date: 06/30/2023
No
Will any PARALYTICS be administered?
No
Will any ANESTHETICS be administered?
No
Will any ANALGESICS be administered?
No
Will CONTROLLED and/or PRESCRIPTION PHARMACEUTICALS be utilized?
No
Will any DRUGS, TOXINS, REAGENTS, CELLS, ETC. (other than analgesics, anesthetics, or
paralytics) be administered?
No
Will DEATH be used as an ENDPOINT?
No
Will any OTHER procedures be utilized that the NPS IACUC should be aware of?
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NPS Form 10-1301 (03/2016)
National Park Service
OMB Control No. 1024-0265
Expiration Date: 06/30/2023
IV. TYPE, FREQUENCY, AND TREATMENT OF INJURIES
Describe the most likely forms of injuries to research animals, how frequent injury(ies) is(are) expected to occur, and planned procedures for
injured animals (treatment or euthanasia).
V. EUTHANASIA AND DISPOSITION
All methods of euthanasia must follow the American Veterinary Medical Association Guidelines for the Euthanasia of Animals.
Any deviations must be scientifically justified.
Describe the PRIMARY method of euthanasia planned as well as a SECONDARY method to ensure animal will not
revive. Include personnel qualifications and experience with the chosen method(s).
Even if you do not intend to euthanize animals at the completion of your project, a method of euthanasia must be listed in cases of emergency.
Disposition of remains:
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NPS Form 10-1301 (03/2016)
National Park Service
OMB Control No. 1024-0265
Expiration Date: 06/30/2023
VI. ANIMAL SURGERY INFORMATION
Yes
Is there surgery planned for this study?
Scientific Name
Common Name
# to be Used
Survival /
Non-Survival
Major/Minor
Scientific Name
Common Name
# to be Used
Survival /
Non-Survival
Major/Minor
Scientific Name
Common Name
# to be Used
Survival /
Non-Survival
Major/Minor
Scientific Name
Common Name
# to be Used
Survival /
Non-Survival
Major/Minor
Scientific Name
Common Name
# to be Used
Survival /
Non-Survival
Major/Minor
No
Will additional animals undergo surgery?
Pre-operative Procedures and Care:
No
Will unhealthy animals be exempted from surgery?
Which individuals are responsible for evaluating pre-operative health status of animals?
Which pre-operative procedures and care will be utilized?
Provide a description of the area where the surgery will be performed, how it is prepared before each surgery, how surgical instruments are
prepared, and how individuals responsible for surgery prepare themselves.
Anesthetic Procedures:
What anesthetic procedures will be used (name, route, dose, frequency, and duration)?
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NPS Form 10-1301 (03/2016)
National Park Service
OMB Control No. 1024-0265
Expiration Date: 06/30/2023
B) Which individual(s) will be performing and monitoring anesthesia?
Surgical Procedures:
Describe the surgical procedures to be performed.
How will aseptic conditions be maintained throughout the surgical procedures?
Who will be performing surgical procedures?
Post-operative Procedures and Care:
Yes
Will there be post-operative monitoring of animals?
Please provide information on the individuals and procedures responsible for post-operative care
and monitoring, including after-hour, weekend, and holiday care.
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NPS Form 10-1301 (03/2016)
National Park Service
No
OMB Control No. 1024-0265
Expiration Date: 06/30/2023
Will post-operative analgesics be used?
Provide justification for withholding post-operative analgesia.
Describe all post-operative procedures and care.
Yes
Will there be use of any antibiotics or other therapeutic drugs?
Please provide name, dose, route, and frequency.
Yes
Does the surgical procedure induce disease, functional alteration, etc.?
Please provide scientific justification for inducing such conditions.
Multiple Surgeries:
Yes
Will animals be subjected to more than one (1) survival surgery?
Please provide scientific justification for why more than one survival surgery is needed.
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NPS Form 10-1301 (03/2016)
National Park Service
OMB Control No. 1024-0265
Expiration Date: 06/30/2023
VII: PERMITS
Permit Number
Permit Type
Expiration Date
VIII. AUDIOVISUAL RECORD
No
Do you have any audiovisual materials to add to your submission?
IV. LITERATURE CITATIONS
No
Do you have additional literature to cite for this project?
Assurance Statement
The information in this general submission 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:
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NPS Form 10-1301 (03/2016)
National Park Service
OMB Control No. 1024-0265
Expiration Date: 06/30/2023
APPENDIX A
Additional Personnel
THIS PAGE INTENTIONALLY LEFT BLANK
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NPS Form 10-1301 (03/2016)
National Park Service
OMB Control No. 1024-0265
Expiration Date: 06/30/2023
APPENDIX B
Additional Study Species
THIS PAGE INTENTIONALLY LEFT BLANK
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NPS Form 10-1301 (03/2016)
National Park Service
OMB Control No. 1024-0265
Expiration Date: 06/30/2023
APPENDIX C
Additional Animals Undergoing Surgery
THIS PAGE INTENTIONALLY LEFT BLANK
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NPS Form 10-1301 (03/2016)
National Park Service
OMB Control No. 1024-0265
Expiration Date: 06/30/2023
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 3 hours 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.
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| File Type | application/pdf |
| File Title | General Submission Form |
| Author | Thompson, Tracy |
| File Modified | 2021-09-02 |
| File Created | 2016-01-12 |