Form 10-1304 IACUC BioBlitz Field Study Form

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

OMB Control No. 1024-0265
Expiration Date: XX/XX/XXXX

BIOBLITZ/FIELD STUDY FORM
INSTITUTIONAL ANIMAL CARE AND USE COMMITTEE
Natural Resources Stewardship and Science Directorate
Biological Resource Management Division
1201 Oakridge Drive, Suite 200
Fort Collins, CO 80525
Telephone: (970) 225-3566 or Email: NPSIACUC@nps.gov

Date:
Principal Investigator (PI) Name:
PI Email:
PI Phone Number:
Date of submission:
Enter the Park Name:
Dates Planned:
To see an example for each field, hover over the

Activities Planned:

Example

Example

SAVE for ATTACHMENT

PRINT FORM

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CLEAR FORM

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

List of possible species and numbers expected to be captured:

OMB Control No. 1024-0265
Expiration Date: XX/XX/XXXX

Example

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

Are any additional procedures to be done as part of the
demonstration?

Example

Example

Who will be involved? Please list their experience and qualifications.

Example

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

OMB Control No. 1024-0265
Expiration Date: XX/XX/XXXX

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 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 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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