Form 3-1383-R Research and Monitoring Special Use Application and Perm

OMB Control Number 1018-0102
Expiration Date: XX/XX/2014

United States Department of the Interior
U.S. Fish and Wildlife Service

National Wildlife Refuge System
Research and Monitoring Special Use
Application and Permit

Name of Refuge
Address

Attn: (Refuge Official)

Application:
(To be filled out by applicant. Note: Not all information is required for each use.
See instructions at the end of the notice for specific information required.)

1)

New

Renewal

Modification

Phone #

E-mail

Other

Applicant Information:
3) Is curriculum vitae

2) Principal investigator:

or resume attached?

4) Address:

Yes

No

N/A

5) City/State/Zip:

6) Phone #:

7) Fax #:

8) E-mail:

9a) Affiliation/organization:
9b) Relationship to affiliation/organization: (professor, staff, student, etc.)
10) Assistants/subcontractors/subpermittees: (List full names, addresses and phone #'s and specifically describe services provided if
subcontractors are used.)

Project Information: (Depending on the project for which you are requesting a permit, we may ask you for the following project information.
Please contact the specific refuge where the project is being conducted to determine what project information is required.)

11) Title:
12a) Is full research proposal required?
Yes

No

12b) Is full research proposal attached?
Yes

No

13) Describe activity: (Specifically identify timing, frequency, and how the project is expected to proceed.)

14) Location: (Identify specific location; GPS location preferred.)

15a) Is map of location(s) required?
Yes

No

N/A

15b) Is map of location(s) attached?
Yes

No

16) Project/site occupancy timeline: (Specifically identify beginning and ending dates, site occupation timeline, hours, clean-up and other major
events.)

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OMB Control Number 1018-0102
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17) Species or habitats being studied:

18) Purpose/hypothesis:

19) Expected benefits of research/monitoring:

20) Briefly describe project history and context of research/monitoring project:

21) Briefly describe project's relationship to other research/monitoring projects either known of or
conducted by the applicant:

22) Identify the types of samples to be taken or data to be collected during the proposed project:

23) List other cooperators and institutions involved in the project:

24) Generally identify the anticipated timeline for analysis, write-up and publication:

25) For research involving animals, has an Assurance of Animal Care Form, Institutional Animal
Yes
No
N/A
Care and Use Committee approval (or equivalent) been completed?
Is form attached?

Yes

No

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OMB Control Number 1018-0102
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Certifications/Permits:
26a) Is rat free certification required?
Yes

No

Copy of certification provided:

N/A

Yes

No

26b) Is hull inspection certification required? Copy of certification provided:
Yes

No

N/A

Yes

26c) Is EMT/first aid certification required?
Yes

No

Copy of certification provided:

N/A

Yes

26d) Are other certifications required?
Yes

No

No

Yes

No

N/A

Yes

No

N/A

Yes

No

No

Copy of permits provided:

N/A

Yes

27d) Are other permits required?
Yes

No

Copy of permits provided:

27c) Are tribal permits required?
Yes

No

Copy of permits provided:

27b) Are Federal permits required?
Yes

No

Copy of certification provided:

N/A

27a) Are State permits required?
Yes

No

No

Copy of permits provided:

N/A

Yes

No

Logistics and Transportation:
28a) Does activity require personnel to stay
overnight onsite?
Yes

28b) Personnel involved:

No

29) Specifically describe all equipment/gear and materials used:

30a) Dates of installation of instrumentation:

30b) Dates of instrumentation removal:

30c) If instrumentation is permanent, describe need:

30d) Instrumentation maintenance schedule:

30e) Data collection schedule:

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OMB Control Number 1018-0102
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31) Logistical arrangements for offsite transportation of samples:

32a) Transportation description(s) and license number(s) to access refuge(s): (Provide description of and specific
auto license/boat/plane registration number(s).)

32b) Specifically describe ship-to-shore transportation:

32c) Specifically describe intersite transportation:

32d) Specifically describe onsite transportation:

33a) Is fuel cache needed?

33b)Specific location(s) of fuel caches:

Yes

No

N/A

34a) Is Safety Plan required?
Yes

No

(GPS Coordinates preferred)

N/A

34b) Safety Plan attached:
Yes

No

Work and Living Accommodations:
35) Specifically describe onsite work and/or living accommodations, including spike camps:

36) Specifically describe on or offsite hazardous material storage or other on or offsite material storage space (including on
and offsite fuel caches):

37) Signature of Applicant________________________________ Date of Application:____________
Print Form

Sign, print, and date this form and return it to the refuge for processing. Do not fill out information below this
page.

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OMB Control Number 1018-0102
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For Official Use Only: (This section to be filled out by refuge personnel only.)

Special Use Permit:

Permit #:
2) Permit
Approved

1) Date:

Permit
Denied

3) Station # :

4) Additional special conditions required: (Special conditions may include activity reports, before and after photographs, and other conditions.)
Yes

No

N/A

5) Other licenses/permits required:
Yes

No

N/A

No

8) Record of Payments:

Yes

No

Yes

No

Approval form attached:
Yes

No

N/A

Exempt

Partial

Amount of payment:
9) Bond Paid:

Assessment attached:

N/A

7) Assurance of Animal Care Form or Institutional Animal
Care and Use approval received :
Yes

No

Verification of other licenses/permits, type:

6) Minimum requirements analysis has been conducted:
Yes

Yes

Additional sheets attached:

Full
Record of partial payment:

No

N/A

This permit is issued by the U.S. Fish and Wildlife Service and accepted by the
applicant signed below, subject to the terms, covenants, obligations, and
reservations, expressed or implied herein, and to the notice, conditions, and
requirements included or attached. A copy of this permit should be kept on hand so
that it may be shown at any time to any refuge staff.
Permit approved and issued by (Signature and title):
________________________________

Date:___________

Permit accepted by (Signature of applicant):
________________________________

Date:___________
FWS Form 3-1383-R
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Notice

OMB Control Number 1018-0102
Expiration Date: XX/XX/2014

In accordance with the Privacy Act (5 U.S. C. 552a) and the Paperwork Reduction Act (44 U.S. C. 3501), please note the following information:
1. The issuance of a permit and collection of fees on lands of the National Wildlife Refuge System are authorized by the National Wildlife Refuge System
Administration Act (16 U.S. C. 668dd-ee) as amended, and the Refuge Recreation Act (16 U.S. C. 460k-460k-4).
2. The information that you provide is voluntary; however submission of requested information is required to evaluate the qualifications, determine eligibility,
and document permit applicants under the above Acts. It is our policy not to use your name for any other purpose. The information is maintained in accordance
with the Privacy Act. All information you provide will be considered in reviewing this application. False, fictitious, or fraudulent statements or representations
made in the application may be grounds for revocation of the Special Use Permit and may be punishable by fine or imprisonment (18 U.S.C. 1001). Failure to
provide all required information is sufficient cause for the U.S. Fish and Wildlife Service to deny a permit.
3. No Members of Congress or Resident Commissioner shall participate in any part of this contract or to any benefit that may arise from it, but this provision
shall not pertain to this contract if made with a corporation for its general benefit.
4. The Permittee agrees to be bound by the equal opportunity "nondiscrimination in employment" clause of Executive Order 11246.
5. Routine use disclosures may also be made: (a) to the U.S. Department of Justice when related to litigation or anticipated litigation; (b) of information
indicating a violation or potential violation of a statute, rule, order, or license to appropriate Federal, State, local or foreign agencies responsible for investigating
or prosecuting the violation or for enforcing or implementing the statute, rule, regulations, order, or license; (c) from the record of the individual in response to
an inquiry from a Congressional office made at the request of the individual (42 FR 19083; April 11,1977); and (d) to provide addresses obtained from the
Internal Revenue Service to debt collection agencies for purposes of locating a debtor to collect or compromise a Federal Claim against the debtor, or to
consumer reporting agencies to prepare a commercial credit report for use by the Department (48 FR 54716; December 6, 1983).
6. 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. This information collection has been approved by OMB and assigned control number 1018-0102. The public reporting burden for this information
collection varies based on the specific refuge use being requested. The relevant public reporting burden for the Research and Monitoring Special Use Permit
Application form is estimated to average 4 hours per response, including time for reviewing instructions, gathering and maintaining data, and completing and
reviewing the form. Comments on this form should be mailed to the Information Collection Clearance Officer, U.S. Fish and Wildlife Service, 4401 N. Fairfax
Drive, MS 2042-PDM, Arlington, Virginia, 22203.
General Conditions and Requirements
1. Responsibility of Permittee: The permittee, by operating on the premises, shall be considered to have accepted these premises with all facilities, fixtures, or
improvements in their existing condition as of the date of this permit. At the end of the period specified or upon earlier termination, the permittee shall give up
the premises in as good order and condition as when received except for reasonable wear, tear, or damage occurring without fault or negligence. The permittee
will fully repay the Service for any and all damage directly or indirectly resulting from negligence or failure on his/her part, and/or the part of anyone of his/her
associates, to use reasonable care.
2. Operating Rules and Laws: The permittee shall keep the premises in a neat and orderly condition at all times, and shall comply with all municipal, county,
and State laws applicable to the operations under the permit as well as all Federal laws, rules, and regulations governing national wildlife refuges and the area
described in this permit. The permittee shall comply with all instructions applicable to this permit issued by the refuge official in charge. The permittee shall take
all reasonable precautions to prevent the escape of fires and to suppress fires and shall render all reasonable assistance in the suppression of refuge fires.
3. Use Limitations: The permittee's use of the described premises is limited to the purposes herein specified and does not, unless provided for in this permit,
allow him/her to restrict other authorized entry onto his/her area; and permits the Service to carry on whatever activities are necessary for: (1) protection and
maintenance of the premises and adjacent lands administered by the Service; and (2) the management of wildlife and fish using the premises and other
Service lands.
4. Transfer of Privileges: This permit is not transferable, and no privileges herein mentioned may be sublet or made available to any person or interest not
mentioned in this permit. No interest hereunder may accrue through lien or be transferred to a third party without the approval of the Regional Director of the
Service and the permit shall not be used for speculative purposes.
5. Compliance: The Service's failure to require strict compliance with any of this permit's terms, conditions, and requirements shall not constitute a waiver or be
considered as a giving up of the Service's right to thereafter enforce any of the permit's terms or conditions.
6. Conditions of Permit not Fulfilled: If the permittee fails to fulfill any of the conditions and requirements set forth herein, all money paid under this permit shall
be retained by the Government to be used to satisfy as much of the permittee's obligation as possible.
7. Payments: All payment shall be made on or before the due date to the local representative of the Service by a postal money order or check made payable to
the U.S. Fish and Wildlife Service.
8. Termination Policy: At the termination of this permit the permittee shall immediately give up possession to the Service representative, reserving, however,
the rights specified in paragraph 11. If he/she fails to do so, he/she will pay the government, as liquidated damages, an amount double the rate specified in this
permit for the entire time possession is withheld. Upon yielding possession, the permittee will still be allowed to reenter as needed to remove his/her property
as stated in paragraph 11. The acceptance of any fee for the liquidated damages or any other act of administration relating to the continued tenancy is not to be
considered as an affirmation of the permittee's action nor shall it operate as a waiver of the Government's right to terminate or cancel the permit for the breach
of any specified condition or requirement.
9. Revocation Policy: This permit may be revoked by the Regional Director of the Service without notice for noncompliance with the terms hereof or for violation
of general and/or specific laws or regulations governing national wildlife refuges or for nonuse. It is at all times subject to discretionary revocation by the
Director of the Service. Upon such revocation the Service, by and through any authorized representative, may take possession of the said premises for its own
and sole use, and/or may enter and possess the premises as the agent of the permittee and for his/her account.
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10. Damages: The United States shall not be responsible for any loss or damage to property including, but not limited to, growing crops, animals, and
machinery or injury to the permittee or his/her relatives, or to the officers, agents, employees, or any other who are on the premises from instructions or by the
sufferance of wildlife or employees or representatives of the Government carrying out their official responsibilities. The permittee agrees to save the United
States or any of its agencies harmless from any and all claims for damages or losses that may arise to be incident to the flooding of the premises resulting from
any associated Government river and harbor, flood control, reclamation, or Tennessee Valley Authority activity.
11. Removal of Permittee's Property: Upon the expiration or termination of this permit, if all rental charges and/or damage claims due to the Government have
been paid, the permittee may, within a reasonable period as stated in the permit or as determined by the refuge official in charge, but not to exceed 60 days,
remove all structures, machinery, and/or equipment, etc. from the premises for which he/she is responsible. Within this period the permittee must also remove
any other of his/her property including his/her acknowledged share of products or crops grown, cut, harvested, stored, or stacked on the premises. Upon failure
to remove any of the above items within the aforesaid period, they shall become the property of the United States.
12. Collected Specimens: You may use specimens collected under this permit, any components of any specimens (including natural organisms, enzymes,
genetic materials or seeds), and research results derived from collected specimens for scientific or educational purposes only, and not for commercial purposes
unless you have entered into a Cooperative Research and Development Agreement (CRADA) with us. We prohibit the sale of collected research specimens or
other transfers to third parties. Breach of any of the terms of this permit will be grounds for revocation of this permit and denial of future permits. Furthermore, if
you sell or otherwise transfer collected specimens of any components without a CRADA, you will pay us a royalty rate of 20 percent of the gross revenue from
such sales. In addition to such royalty, we may seek other damages and injunctive relief against you.
Instructions for Completing Application
You may complete the application portion verbally, in person or electronically and submit to the refuge for review. Note: Please read instructions carefully as
not all information is required for each activity. Contact the specific refuge where the activity will take place if you have questions regarding the applicability of a
particular item. Special conditions or permit stipulations may be added to permit prior to approval.
1. Identify if application is for a new permit or renewal or modification of an existing permit. Permit renewals may not need all information requested. Contact
the specific refuge headquarters office where the project is going to be conducted to determine applicability of this requirement.
2-3. Provide principal investigator's or applicant's full name. Attach principal investigator's Curriculum Vitae or Resume, if required. Permit renewals generally
do not require a Curriculum Vitae or Resume if the project is a continuation of a previously issued permit being conducted by the same investigator. Contact the
specific refuge headquarters office where the project is going to be conducted to determine applicability of this requirement.
4-9. Provide investigator's address, phone, fax, e-mail, affiliation and or organization, and relationship to affiliation or organization (title, professor, student, etc.).
10. Provide the names and addresses of assistants, subcontractors or subpermittees. Names and address are only required if the assistants, subcontractors or
subpermittees will be operating on the refuge without the permittee being present. Volunteers, assistants, subcontractors or subpermittees that are
accompanied by the permittee need not be identified.
11. Provide title of research or monitoring project.
12a-12b. Attach a full research or monitoring proposal, if required. Permit renewals generally do not require a project proposal if the project is a continuation of
a previously issued permit being conducted by the same investigator. Contact the specific refuge headquarters office where the project is going to be
conducted to determine applicability of this requirement.
13. Describe Activity: provide detailed information on the activity, including timing, frequency, how the project is expected to proceed, etc. Permit renewals may
not need activity description, if the activity is unchanged from previous permit. Most repetitive research projects do not require an activity description for each
visit to the refuge. Contact the specific refuge headquarters office where the project is going to be conducted to determine applicability of this requirement.
14. Location: identify specific location (GPS coordinates preferred), if not a named facility. Permit renewals may not require a location if the project is essentially
unchanged from the previous permit. Contact the specific refuge headquarters office where the project is going to be conducted to determine applicability of
this requirement.
15a-15b. Attach a map of location, if required and project is not conducted at a named facility. Permit renewals may not require a map if the project is
essentially unchanged from the previous permit. Contact the specific refuge headquarters office where the project is going to be conducted to determine
applicability of this requirement.
16. Activity/site occupancy timeline: identify beginning and ending dates, site occupation timeline, hours, clean-up and other major events. Permit renewals
may not need an activity/site occupancy timeline, if the activity is unchanged from previous permit. Contact the specific refuge headquarters office where the
project is going to be conducted to determine applicability of this requirement.
17. Identify species or habitats being studied.
18-19. Specifically identify purpose or hypothesis of the research or monitoring project and describe expected benefits. Permit renewals may not need to
identify purpose or hypothesis, if the project is a continuation of a previously issued permit being conducted by the same investigator. Contact the specific
refuge headquarters office where the project is going to be conducted to determine applicability of this requirement.
20. Briefly describe project history and context. Permit renewals should describe previous research activities as part of a previously issued permit being
conducted by the same investigator. Contact the specific refuge headquarters office where the project is going to be conducted to determine applicability of this
requirement.

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21. Briefly describe project's relationship to other research/monitoring projects either known of or conducted by the applicant, if applicable. Include a brief
statement of how the research or monitoring permit being applied for will add to or supplement other ongoing research or monitoring on the same, or related,
species or habitats. Contact the specific refuge headquarters office where the project is going to be conducted to determine applicability of this requirement.
22. Identify samples to be taken or types of data to be collected. Permit renewals may not need to identify samples taken if the project is a continuation of a
previously issued permit being conducted by the same investigator. Contact the specific refuge headquarters office where the project is going to be conducted
to determine applicability of this requirement.
23. List other cooperators and institutions involved in the project, if applicable. Contact the specific refuge headquarters office where the project is going to be
conducted to determine applicability of this requirement.
24. Generally, identify the anticipated time line for analysis, write-up and publication of project results. Include whether the project is a single, or multiple year
project. Identification of an actual publication where the results are printed is not necessary. However, applicants should include the anticipated dissemination
of project results. Contact the specific refuge headquarters office where the project is going to be conducted to determine applicability of this requirement.
25. Check box acknowledging a completed Assurance of Animal Care Form or an Institutional Animal Care and Use Committee (or equivalent) has granted
approval been completed, and has been submitted to refuge station, if required. Contact the specific refuge headquarters office where the project is going to be
conducted to determine applicability of this requirement.
26a-26c. Specifically identify types and numbers of other certifications, if required. Contact the specific refuge headquarters office where the project is going to
be conducted to determine applicability of this requirement, and to coordinate the simultaneous application of several types of certifications. This Special Use
Permit may be processed while other certifications are being obtained.
27a-27d. Specifically identify types and numbers of other State, Federal or tribal permits, if required. Contact the specific refuge headquarters office where the
project is going to be conducted to determine applicability of this requirement, and to coordinate the simultaneous application of several types of State, Federal
or tribal permits. This Special Use Permit may be processed while other State, Federal or tribal permits are being obtained.
28a-28b. Provide name(s) of any personnel required to stay overnight, if applicable.
29. Identify all equipment and materials, which will be used, if required. Permit renewals may not require a list of equipment if the project is essentially
unchanged from a previously issued permit. Contact the specific refuge headquarters office where the project is going to be conducted to determine
applicability of this requirement.
30a-30e. Identify types and dates of installation of any instrumentation, and data collection and maintenance schedule of instrumentation, if required. Permit
renewals may not require a list of equipment if the project is essentially unchanged from a previously issued permit. However, dates of installation of any
instrumentation, and data collection and maintenance schedule of instrumentation may still be required. Contact the specific refuge headquarters office where
the project is going to be conducted to determine applicability of this requirement.
31. Identify logistic arrangements for offsite transportation of samples taken, if applicable.
32a-32d. Describe and provide vehicle descriptions and license plate or identification numbers of all vehicles, including boats and airplanes, if required. Motor
vehicle descriptions are only required for permittee vehicle, and/or if the vehicle will be operated on the refuge without the permittee being present. Motor
vehicles that are accompanied by the permittee as part of a group (convoy) activity need not be identified if cleared in advance by refuge supervisor.
Specifically describe ship-to-shore, intersite (between islands, camps, or other sites) and onsite transportation mechanisms, and license plate or identification
numbers, if required.
33a-33b. Identify specific location(s) of fuel cache(s) (GPS coordinates preferred), if required.
34a-34b. Attach safety plan, if required. Contact the specific refuge headquarters office where the project is going to be conducted to determine if a safety plan
is required.
35. Specifically describe onsite work and/or living accommodations, if required. Include descriptions and locations (GPS coordinates preferred) of spike camps
or other remote work and/or living accommodations that are not part of the base of operations. Contact the specific refuge headquarters office where the
project is going to be conducted to determine if descriptions of onsite work and/or living accommodations are required.
36. Specifically describe onsite and offsite hazardous material storage, or other onsite material storage space (including on and offsite fuel caches), if required.
Contact the specific refuge headquarters office where the project is going to be conducted to determine if descriptions of hazardous material storage or other
onsite material storage are required.
37 Sign, date and print the application. Click on the Print button to print the application (if using the fillable version). The refuge official will review and, if
approved, fill out the remaining information, sign, and return a copy to you for signature and acceptance.

The form is not valid as a permit unless it includes refuge approval, a station number, a refuge-assigned permit
number, and is signed by a refuge official.

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