NMMTB form

I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I

Page 1

National Marine Mammal Tissue Bank Form ^{MESB Sample Processing -}

Field ID: Other ID Numb er:

Common Name: ^{Genus species:} _{-----------------}

Stranding Type: Single D Incidental Take...... [a Fisheries ltll other (specify): (choose all -- , [g] Mass D Live Capture..... Rescue ot h er (specify): that apply) UME D Subsistence Add'I. Remar ks:
Condition : I ® Alive © Fresh Dead ® Euthanized I (choose one) If euthanized, with what and how much:
Was animal in rehabilitation? I @ Yes @ No I If yes: _J Where: From: (choose one) (please attach c/linicaf/medical records) To:	dd /mm/ yy
	dd / mm I yy
Animal Location: Stat e: --- County: City/Island/Community: Ocean/Bay/Sea: Locality Details : Latitude: N Lon gitude: w
Time of death (Zulu)......... dd / mm/ yy hr Place of Death: Internal body temp. of animal: l@ c Q FI Rigor? l(i) Yes Q No l If transported before tissue removal: - Vehicle Type: Length of Transport: Ambient weather condition : Remarks: - Time of tissue removal (Zulu).... dd / mm/ yy hr Place of tissue removal: If transported before processing: Transportationstorage: [5] Dryice □ Wetice Other: Ambient weather condition: Interim storage of tissue: D Teflon bag li5l Teflon jar Other: Remarks: Time of tissue processing .... dd / mm/ yy --hr Place of tissue processing: Ambi ent temperature at processing: Tim e of int erim fr eezin g..... dd / mm I yy --hr Freezer type : [El LN2 [a -80degC loJ - 30degC other: Tim e shipped to MESB........ dd / mm/ yy --hr Tim e received at MESB....... dd / mm/ yy --hr

Additional comments:

_{sample wejghts·} Blubb er (g): Liver (g): Kidney (g):

Whole

Blood (ml): ^{Plasma (ml) Serum (ml): other:}

A

B

0MB Co ritrol Nlo.: 0-648-0468

Expiration Date : 03131/2018

National Marine Mammal Tissue Bank Form

Anim al Information - Page 2

Field ID: ^{Genus species:} _{-------------}

Sex: ^{I@) Female Ii) Male} _I Total length :

(;) Adult Q Subadult © Actual

Pup/ca lf ^{@ Yearling @) Estimat ed} Unknown

Total weight :

Age Class:

G Actual ® Estimated _I

^{G kg} @ lb I

^{6 cm} Q i n 1

0 Actual @J Estimat ed _I

Age: GLG's: Other :

(choose one)

Right:

---

Mid-Width: Mid-depth :

Length :

Left : _---

Testis/ Ovari es:

(cicle one)

Reproductive condition:

laJ Sexually Mature

[EID Pregnant

[al Lactating Fetus length :

Epiphysi s: _I ® Open @ Closed fused @) Fused invis _I

Method used: By whom:

Date aged:

^dd /mm I VY

---

Corpora hemmorghagicum #:

---

---

Corpora albicantia #:

---

n

Corpora lut ea #:

b

Weight:

---

---

n

^{Specify Units of Measurement:} ® cm in

Cetaceans :			----l---; Girth: Axilla ry: Max: ;:=A.n.a.l.: ---==----(Location) 1 Blubber th ickness: Thoracic: Dorsal: Lateral : UR/ LR: Ventral:
Snout to ant. ins. of flipper:
Snout to center of genitaI apertur e:
Snout to center of anus:
Flipp er length :
Fluk e width:
Fluk e notch to anus :
Total counts:	UL/ LL:
Pinnipeds:			Ant. length of hind flipper: Blubber th ickness over post. end of sternum: Other blubb er thi ckness:						(Location)
Nose to tail length:
Ant. length of foreflipper :
Axillary girth:
Bacculum length :
Polar Bears: Girth of neck of axis : Girth of neck at should ers:			Skull length:
Sea Otters:
Snout to angl e of mouth :			Right for epaw width:
Skull length : Axillary girth:			Skull width: Tooth Wear: I	Heavy		@ Med.	0	Light	G None I
Extimat e of body fat st ores: _			Subcutaneous:	None: 0	Litt le: @	Average: 0	Excessive: ®
			Groin: --- cm Kidneys: Mesenteric:	© 0 ®	© © ®	Q @ Gl	@ 0 a

0 M B Co11trnl No_: 0648-0468

Expiration Date : 03131/2018

National Marine Mammal Tissue Bank

Additional Samples List - Page 3

I

Field ID Number: _{-------------} Was animal necropsied? I@ Yes @ No

Necropsied by:

(Please attach necropsy report)

Genus species:

dd /mm/ yy

Date

Samples collected:

Histological samples:

Liver	lg] Kidney	[g] Blubber	[g Stomach	lg] Heart	[QI Intestine
ID] Lung	lg] Pancreas	[g] AdrenaIs	oc:J Brain	lg] Muscle	[g] Skin

Individual/Organization: FinaI destination:

Tissues sampled :

(Choose all that apply)

Trachea lg] Spleen [Q] Thymus [QI Colon lg] Thyroid [QI Esophagus

Other:

(Please list)

Lymph Nodes: IMI Submandibular Q Prescapular IQ Axillary [g Hilar

Other l.n.:

IMI Mesenteric

Other samples collected: ^{Type of storage:}

(Z-frozen, F-formalin, DMSO, ETOH)

Where located <Ind./ Org.) :

Teeth:

Genetics (skin):

Skull:

Reproductive tract: Mammary tissue : Ovaries: Gonads/testes: Parasites:

• list type and location:

Stomach:

• list contents if applicable: .......

other contaminant samples:-

(Ust tissue type, storage type and where located)

Additional samples: ^- (List tissue type, purpose of collection, storage type and where located)

^{------------------------------------} I

I

0MB Co11tro l No.: 0 648-046 8

Expiration Date : 03131/2018

National Marine Mammal Tissue Bank

General Notes - Page 4

Field ID Numb er : Photos taken: I (J) Yes ® No I ! @ Digital @ Film Video t aken: I @ Yes © No I Disposition: (primary location for photos and/or video) -	I If	yes, how many?	Genus species: (send copy with samples for NIST archive)		I
General comments: (Reid notes) General appearance of individual:- General appearance of organs:- I NMMTB Prot ocol: ® Standard @ Modified I Please note any modifications: -	I				I I I

Form pr epared by : Name Affiliation

A copy of this form and Level A Data Form should be shipped with samples to: ATTN: Reb ecca Pugh National Institute of Standards and Technology Hollings Marine Laboratory 331 Fort Johnson Rd Charleston, SC 29412 (843) 762-8952

,O M B Co11tro l No.: 064 8-0468

Ex pir ation Date : 0313112:018

Page 5

National Marine Mammal Tissue Bank ^{Chain of Custody -}

NMMTB's Chain of Custody

Field ID Number: other ID Number:

NMMTB Reference/Storage ID Numbers:

1.

Collector's signature

Method of transfer to processing stage

dd /mm/ yy

Date

2.

Processor's signature

Method of transfer to shipping stage

dd /mm/ yy

Date

3.

Shipper to NMMTB's signature

Method of transfer to MESB

dd /mm/ yy

Date

4.

Receiver's signature

dd /mm/ yy

Date

Each person in possession of the tissue must sign and date the form.

PAPERWORK REDUCTION ACT INFORMATION

PUBLIC REPORTING BURDEN FOR THE COLLECTION OF INFORMATION JS ESTIMATED TO AVERAGE :6 0 "11NUTES PER RESPONSE, INCLUDING THE TIME FOR REVIEWING INSTRUCTIONS, SEARCHING EXISTING DATA SOURCES, GATHERING AND MAJNTAJNJNG THE DATA NEEDED, AND COMPLETING AND REVIEWING THE COLLECTION OF l NFORMATJON. SEND COMMENTS REGARDING THIS BURDEN ESTIMATE OR ANY OTHER ASPECT OF THE COLLECTJON INFORMATJON, INCLUDING SUGGESTJONS FOR REDUCING THE BURDEN TO: CHIEF, MARINE MAMMAL AND SEA TURTLE CONSERVATJON DIVJSJON, OFFICE OF PROTECTED RESOURCES, NOAA FISHERIES, 1315 EAST-WEST HIGHWAY, SILVER SPRING, MARYLAND 20910. NOT WITHSTANDING ANY OTHER PROVISION OF THE LAW, NO PERSON JS REQUIRED TO RESPOND, NOR SHALL ANY PERSON BE SUBJECTED TO A PENALTY FOR FAILURE TO COMPLY WITH, A COLLECTJON OF JNFORMATJON SUBJECT TO THE REQUIREMENTS OF THE PAPERWORK REDUCTJON ACT, UNLESS THE COLLECTJON OF INFORMATION DISPLAYS A CURRENTLY VALID OFFICE OF MANAGEMENT AND BUDGET (0MB) CONTROL NUMBER.

Privacy Act Statement

Authority: The collection of this information is authorized under 5 U.S.C. § 301, Departmental regulations and 15 U.S.C. 1512, Powers and duties of Department.

Purpose: As part of the signed Data Submission Agreements, data providers’ and principal investigators’ name, email, and physical address are recorded as part of the metadata for the submitted data set, and for contact purposes when needed. Information on the data providers and principal investigators is necessary in order for a system administrator to contact an individual in the event of a problem during the archiving process. Such information is also necessary to identify the sources of data, especially for properly crediting the providers and principal investigators on the individual holdings in the archive.

Name, email and address may be collected for those requesting data, so that they may open an account through which to receive the data.

Routine Uses: Disclosure of this information is permitted under the Privacy Act of 1974 (5 U.S.C. Section 552a) to be shared among Department staff for work-related purposes. The Department will use this information to contact data providers in the event of a problem during the archiving process, and to properly credit providers and principal investigators on the individual holdings in the archive. Disclosure of this information is also subject to all of the published routine uses as identified in the Privacy Act System of Records Notice COMMERCE/NOAA-11, Contact Information for Members of the Public Requesting or Providing Information Related to NOAA’s Mission.

Disclosure: Furnishing this information is voluntary; however, failure to provide accurate information may delay or prevent required contacts regarding archiving problems, proper archiving, and provision of data.

OMB Control No. 0648-0468

Expiration Date: 3/31/2018