National Marine Mammal Tissue Bank 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

Blubber_

Kidney

Blood

Other
List other type:
Title of Project:
Research Location:
Type of Research:
Estimated Date of Completion:
Attach the following items:
1)
2)
3)
4)
5)

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;
Copy of the scientific research permit;
Verification that funding is available to conduct the research;
Table 1 filled out completely;
A signed copy of the National Marine Mammal Tissue Bank Agreement Form

OMB Control No. 0648-0468 (expires XX/XX/20XX)

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

NMMTB
Storage ID

ex. MMES2004100SC NM10L101C

Species

Common
Name

Tursiops truncatus

Bottlenose dolphin

Tissue
Year
Requested Collected Sex
Liver

2004

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

OMB Control No. 0648-0468 (expires XX/XX/20XX)

F

Age Pregnant or
Size of sample
Class Lactating Requested (i.e. 1ml, 2g, 5g)
Adult

No

2g

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 (former) 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 at the NIST Biorepository at
the Hollings Marine Laboratory, Charleston, SC, 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

Affiliation

PAPERWORK REDUCTION ACT INFORMATION
A Federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply with
an information collection subject to the requirements of the Paperwork Reduction Act of 1995 unless the information collection has a currently valid OMB
Control Number. The approved OMB Control Number for this information collection is 0648-0468. Without this approval, we could not conduct this
survey/information collection. Public reporting for this information collection is estimated to be approximately 3 hours per response, including the time for
reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the information collection.
All responses to this information collection are mandatory. Send comments regarding this burden estimate or any other aspect of this information collection,
including suggestions for reducing this burden to the National Marine Fisheries Service at: 1315 East West Highway, 13th Floor, Silver Spring, MD 20910,
Attn: Sarah Wilkin, Coordinator, Marine Mammal Health and Stranding Response Program,
[email protected] if desired.

OMB Control No. 0648-0468 (expires XX/XX/20XX)