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

OMB Control # 1018-0102
Expiration Date: XX/XX/2017

Research and Monitoring
Special Use Permit Application
For Official Use Only

Refuge Name:
Address:

Approved Permit #:

Attn: (Refuge Official)

Station #:

E-Mail:

Permit Term: from

to

Phone #:
Note: We do not require all information for each Research project. See instructions at the end of the notice and contact the refuge
to determine applicability of a particular item. Attach additional sheets if the text spaces provided are inadequate.
1) Identify the type of Permit you are applying for:

New

Renewal

Modification

Other

Applicant Information
2) Principal investigator:

3) Is curriculum vitae or resume attached?

Yes

No

4a) Affiliation/Sponsoring Organization:
4b) Relationship to affiliation/sponsoring organization (professor, staff, student, etc.):
5) Street Address:
6) City/State/Zip:
7) Phone #:

8) Fax #:

9) E-mail:

10) List known assistants/subcontractors/subpermittees: (Only required if the assistants/subcontractors/subpermittees will be operating on the refuge without
the permittee being present.)

Name

Address

Phone #

Project Information
11) Title of project:
12a) Is full research proposal required?

Yes

No

12b) Is full research proposal attached?

Yes

No

Note: Depending on the research and monitoring project for which you are requesting a permit, we may ask you for the following
project information (13 -25) if it is not included in your research proposal, or if you have not provided a full research proposal with
this application. Please contact the specific refuge where the activity is being conducted to determine what information is required.
Attach additional sheets to the application if the text spaces provided are inadequate.
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13) Describe project by specifically identifying timing, frequency, and how the project is expected to proceed:

14) Specifically identify location(s) for the project: (GPS location(s) preferred)

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

No

N/A

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

No

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

17) Identify 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:

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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 Care and

Is form attached?

Use Committee approval (or equivalent) been completed?

Yes

Yes

No

N/A

No

License/Insurance/Certifications/Permits
Note: Contact the specific refuge office where the research project is going to be conducted to determine if any type of license,
insurance, certification(s), or permit(s) will be required. We may process this Special Use Permit while the applicant obtains them.
Attach additional sheets to the application if the text spaces provided are inadequate.
26a) List any licenses you have for equipment operation (i.e., aviation or commercial boats), pesticide applications, transporters, or others if
required:
License Type

Number

Expiration Date (if applicable)

Copy Attached? Yes/No

26b) List any insurance you have, such as general liability, flight/grounding, contaminants, medical evacuation, or others if required:
Insurance Type

Carrier

Expiration Date (if applicable)

Copy Attached? Yes/No

26c) List any certifications you have, such as rat free, hull inspections, CPR/First Aid, or others if required:
Certificate Type

Expiration Date (if applicable)

Copy Attached? Yes/No

26d) List any other Federal, State, or Tribal permits if required:
Permit Type

Permit Number

Expiration Date (if applicable)

Copy Attached? Yes/No

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Logistics and Transportation Attach additional sheets if the text spaces provided are inadequate.
27a) Does project require personnel to stay overnight on the refuge?
27b) If yes, how many?

Yes

No

And list known personnel involved in overnight stay below:

List Names

List Names

List Names

List Names

28) Specifically describe all major instrumentation/equipment/gear and materials used, if applicable or required:

29a) Provide details and schedule for the installation of instrumentation:

29b) Provide details and schedule for the removal of instrumentation:

29c) If instrumentation is permanent, describe need:
30d) Specifically describe onsite transportation:

29d) If instrumentation requires a maintenance schedule, describe needs and schedule:
30d) Specifically describe onsite transportation:

29e) Provide a data collection schedule:
30d) Specifically describe onsite transportation:

30) Provide logistical arrangements for offsite transportation of samples:
30d) Specifically describe onsite transportation:

31a) Provide detailed information on the logistics for onsite, intersite, and/or ship-to-shore transportation to or on the refuge, if required:

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31b) Provide descriptions, license plate and/or identification numbers of vehicles used for onsite transportation, if required:
Vehicle Type

Plate/I.D./Registration #

Vehicle Type

Plate/I.D./Registration #

31c) Provide descriptions, license plate and/or identification numbers of vehicles used for intersite transportation, if required:
Vehicle Type

Plate/I.D./Registration #

Vehicle Type

Plate/I.D./Registration #

31d) Provide descriptions, license plate and/or identification numbers of vehicles used for ship-to-shore transportation, if required
Vehicle Type

32a) Is fuel cache needed?

Plate/I.D./Registration #

Yes

No

N/A

33a) Is Safety Plan required?
Yes

No

N/A

Vehicle Type

Plate/I.D./Registration #

32b) Provide specific location(s) of fuel caches: (GPS coordinates preferred)

33b) Is Safety Plan attached?
Yes

No

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

35) Specifically describe on or offsite hazardous material storage or other on or offsite material storage space: (Including on and offsite fuel caches.)

Sign, date, and print this form and return it to the refuge for processing.

36) Signature of Applicant: _______________________________________Date of Application: ___________________________________

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Notice
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:
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).
The information that you provide is voluntary; however, we require submission of requested information 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. We maintain the information in
accordance with the Privacy Act. We will consider all information you provide 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.
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.
The Permittee agrees to be bound by the equal opportunity “nondiscrimination in employment” clause of Executive Order 11246.
We also may make routine use disclosures: (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 of Justice (48 FR 54716; December 6, 1983).
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. OMB has approved this information collection and assigned control number 1018-0102. The public reporting burden for this
information collection varies based on the requested specific refuge use. We estimate the relevant public reporting burden for the Research and Monitoring
Activity Special Use Permit Application form is to average 5 hours per response, including time for reviewing instructions, gathering and maintaining
data, and completing and reviewing the form. Mail comments on this form 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: We shall consider the permittee, by operating on the premises, 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 allows the U.S. Fish and Wildlife Service to carry on whatever activities
are necessary for: (1) protection and maintenance of the premises and adjacent lands administered by the U.S. Fish and Wildlife Service; and (2) the
management of wildlife and fish using the premises and other U.S. Fish and Wildlife 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 U.S. Fish and Wildlife Service and the permit shall not be used for speculative purposes.
5) Compliance: The U.S. Fish and Wildlife 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 U.S. Fish and Wildlife 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, the U.S. Fish and Wildlife Service
shall retain all money paid under this permit 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 U.S. Fish and Wildlife 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 U.S. Fish and Wildlife Service
representative, reserving, however, the rights specified in paragraph 11 below. If he/she fails to do so, he/she will pay the U.S. Fish and Wildlife
Service, as liquidated damages, an amount double the rate specified in this permit for the entire time possession is withheld. Upon yielding
possession, we will still allow the permittee to reenter as needed to remove his/her property as stated in paragraph 11 below. The acceptance of any
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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 U.S. Fish and Wildlife Service’s right to terminate or cancel the permit for the breach of any
specified condition or requirement.
9) Revocation Policy: The Regional Director of the U.S. Fish and Wildlife Service may revoke this permit 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 U.S. Fish and Wildlife Service, by and through any authorized
representative, may take possession of 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.
10) Damages: The U.S. Fish and Wildlife Service shall not be responsible for: any loss or damage to property including but not limited to crops,
animals, and machinery; injury to the permittee or his/her relatives or to the officers, agents, employees, or any other(s) who are instructed to be on
the premises; the sufferance from wildlife or employees or representatives of the U.S. Fish and Wildlife Service carrying out their official
responsibilities. The permittee agrees to hold the U.S. Fish and Wildlife Service 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 U.S. Fish
and Wildlife Service have been paid, the permittee may, within a reasonable period as stated in the permit or as determined by the U.S. Fish and Wildlife
Service 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 also must 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 U.S. Fish and Wildlife Service.
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. We may add special conditions or permit stipulations 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.
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 office to determine applicability of this requirement.
4-9) Provide investigator’s address, phone, fax, e-mail, affiliation and/or sponsoring organization, and relationship to affiliation or organization
(title, professor, student, etc.).
10) Provide the names and addresses of assistants, subcontractors, or subpermittees. We may require names and addresses if the assistants, subcontractors or
subpermittees will be operating on the refuge without the permittee being present. Volunteers, assistants, subcontractors, or subpermittees
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 office to determine applicability of this requirement.
13) 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 office to determine applicability of this requirement.
14) 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 office to determine applicability of this requirement.
15a-15b) Attach a map of location, if required, and if the 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 office to determine applicability of this requirement.
16) 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 office 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 office 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 office 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 office 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 office to determine applicability of this requirement.
23) List other cooperators and institutions involved in the project, if applicable. Contact the specific refuge office 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 office 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) that
has granted approval has been completed, and has been submitted to refuge station, if required. Contact the specific refuge office to determine
applicability of this requirement.
26a-d) Specifically identify types and numbers of licenses, insurance, certifications, and 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 these requirements, and to coordinate the
simultaneous applications of any of these requirements while this Special Use Permit is being processed.
27a-27b) Provide the number of and/or name(s) of any personnel required to stay overnight on the refuge, if applicable.
28) Identify all equipment and materials that 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 office to determine applicability of this requirement.
29a-29e) Identify types and schedule(s) of installation of any instrumentation, 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, schedules
of installation of any instrumentation, 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.
30) Identify logistical arrangements for offsite transportation of samples taken, if
applicable.
31a-31d) 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.
32a-32b) Identify specific location(s) of fuel cache(s) (GPS coordinates preferred), if required.
33a-33b) Attach safety plan, if required. Contact the specific refuge office to determine applicability of this requirement.
34) 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 office to determine
applicability of this requirement.
35) 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 office to determine if descriptions of hazardous material storage or other onsite material storage are required.
36) 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.

This application form is not valid as a permit
but may be used as a reference document attached to the official permit.
Only official refuge personnel may assign a valid permit number and permit term to this application form
after the permit has been approved.

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