Form 10-946 NPS National Underground Railroad Network to Freedom App

NPS Form 10-946 (07/2016) OMB Control No. 1024-0232

National Park Service Expiration Date XX/XX/XXXX

NATIONAL UNDERGROUND RAILROAD

NETWORK TO FREEDOM APPLICATION

GENERAL INFORMATION
Date Submitted:	Resubmission:						Type (Pick One):
     	Yes No			Round:		     	Site Facility Program
Name (Of What You Are Nominating):							Street Address:
     							     
City:		State:			Zip Code:		County:	Congressional District:
     		     			     		     	     
Physical Boundaries of Site/Facility								Address Not for Publication?
     
Is there a website?			Web Address:
Yes No			     
Is there a visitor phone number?			Phone Number:
Yes No			     
Summary: Tell us in 200 words or less what is being nominated and how it is connected to the Underground Railroad.
     

Owner/Manager (Share Contact Information Yes No)

Name:

Phone:

Fax:

Email:

     

     

     

     

Street Address:

City

State:

Zip Code

     

     

     

     

Owner/Manager (Share Contact Information Yes No)

Name:

Phone:

Fax:

Email:

     

     

     

     

Street Address:

City

State:

Zip Code

     

     

     

     

Owner/Manager (Share Contact Information Yes No)

Name:

Phone:

Fax:

Email:

     

     

     

     

Street Address:

City

State:

Zip Code

     

     

     

     

Owner/Manager (Share Contact Information Yes No)

Name:

Phone:

Fax:

Email:

     

     

     

     

Street Address:

City

State:

Zip Code

     

     

     

     

Owner/Manager (Share Contact Information Yes No)

Name:

Phone:

Fax:

Email:

     

     

     

     

Street Address:

City

State:

Zip Code

     

     

     

     

SITES

In addition to the responses to each question, applications must also include the following attachments: Letters of consent from all property owners for inclusion in the Network to Freedom (see sample in instructions) Text and photographs of all site markers Original photographs illustrating the current appearance and condition of the site being nominated Maps showing the location of the site All attachments supplement, but do not replace the text.

S1. Type:

Building

Object

District (Neighborhood)

Structure

Landscape/Natural Feature

Archeological Site

Other (Describe):      

S2. Is the site listed in the National Register of Historic Places?

Yes No

If yes, what is the listing name?

     

S3. Ownership of site:

Private Private, Non-profit (501c3) Public - Local Government Public - State Government Public - Federal Government

S4. Type(s) of Underground Railroad Association (select the one(s) that fit best):

Station

Kidnapping

Legal Challenge

Association with Prominent Person

Escape

Rescue

Maroon Community

Historic District/Neighborhood

Church

Destination

Transportation Route

Commemorative Site/Monument

Cemetery

Military Site

Archeological Site

Other (Describe):

     

S4a. Describe the site’s association and significance to the Underground Railroad. Provide citations for sources used throughout the text. Timelines are encouraged.

     

S5. Provide a history of the site since its time of significance to the Underground Railroad, including physical changes, changes in boundaries over time, archeological work, or changes in ownership or use. Be sure to describe what is included in the present application and how that compares to what the site was historically.
     
S6. Include a bibliography or list of citations for sources used through the document. Discuss the reliability of historical sources of information and briefly discuss how you used them.
     
S7. Describe current educational programs, tours, markers, signs, brochures, site bulletins, or plaques at the site. Include text and photographs of markers.
     
S8. Describe any local, State, or Federal historic designation, records, signage, or plaques at the site.
     
S8. Describe any local, State, or Federal historic designation, records, signage, or plaques at the site.
     
S9a. Is the site open to the public? Yes No	Days and Hours of Operation:      
S9b. If open, describe accessibility conditions under the Americans with Disabilities Act.
     
S10. Describe the nature and objectives of any partnerships that have contributed to the documentation, preservation, commemoration, or interpretation of the site.
     

S11. Additional data or comments. (Optional) These brochures and excerpts from sources do not replace the required narrative.
     
FACILITIES
In addition to the responses to each question, applications must also include a letter of consent for inclusion in the Network to Freedom from the facility owner or manager.
F1. Type:	Archive	Library	Research Center	Other (Describe):      
F2. Provide a general description of the facility and its purpose or mission.
     
F3. Describe the holdings or collections and discuss their significance to the Underground Railroad.
     
F4. List the Underground Railroad or slavery-related items or materials in the facility.
     
F5. Describe the documents the facility has to verify the sources of its collections.
     
F6. Describe the indexes or finding aids that are available for the facility’s collections.
     
F7. Describe the facility’s management and staff, and levels of training or certifications.
     

F8. Describe the types of publications, reports, or services the facility performs or produces.

     

F9. Describe the conditions of public use at the facility, including accessibility under the Americans with Disabilities Act. Describe what personal assistance visiting researchers receive.

     

F10. Describe visitation workload at the facility.

     

F11. Describe the facility’s traveling exhibit, interlibrary-loan, and photocopying or duplication policies and capabilities.

     

F12. Describe the nature and objectives of any partnerships that have contributed to the operation of the facility.

     

F13. Additional data or comments. (Optional)

     

EDUCATIONAL AND INTERPRETIVE PROGRAMS

In addition to each question, applications must also include the following attachments:

1. Letters from people consulted in the development of the interpretive program describing their input and participation in the process.

2. An example of an audience feedback card or questionnaire or other audience feedback mechanism.

3. A letter of consent for inclusion in the Network to Freedom from the owner or manager of the program.

4. A DVD or video of the program or a sample of the program for evaluation purposes. See instructions for use policy. (Optional but recommended.)

P1. Describe the program.

     

P1. Type:	Public Program	Tour	Performance	Living
	Exhibit	Website	Curriculum-based Education	Youth Program
	Other (Describe):      
P2. What do you want your audience to know about the Underground Railroad, and how is it presented?
     
P3. Describe what advice you sought in developing your program.
     
P4. Identify historical sources of information and describe how they were used to develop the program. Include a bibliography.
     
P5. Describe the educational objectives of the program, tour, or performance.
     
P6. For whom is the program intended? Is the program fully accessible to all?
     
P7. Describe where the program has been presented.
     
P8. Describe how the program is evaluated and how you use the results to improve the program.
     

P9. How long has the program existed and what are the future plans for the program.

     

P10. Describe the program’s management and staff, and levels of training or certification.

     

P11. Describe the nature and objectives of any partnerships that have contributed to the program.

     

P12. Additional data or comments. (Optional)

     

NOTICES

Privacy Act Statement

General: This information is provided pursuant to Public Law 93-579 (Privacy Act of 1974), December 21, 1984, for individuals completing this form.

Authority: National Underground Railroad Network to Freedom Act (P.L. 105-203).

Purpose and Uses: The Network to Freedom was established, in part, to facilitate sharing of information among those interested in the Underground Railroad. Putting people in contact with others who are researching related topics, historic events, or individuals or who may have technical expertise or resources to assist with projects is one of the most effective means of advancing Underground Railroad commemoration and preservation. Privacy laws designed to protect individual contact information (i.e., home or personal addresses, telephone numbers, fax numbers, or e-mail addresses), may prevent NPS from making these connections. If you are willing to be contacted by others working on Underground Railroad activities and to receive mailings about Underground Railroad-related events, please add a statement to your letter of consent indicating what information you are willing to share. The DOI and NPS may use the information to meet reporting requirements, to generate budget estimates and track performance, and to assist park staff with visitors’ education, fee collection, resource management and protection, recreational use planning, law enforcement and public safety personnel for such purposes as emergency contact and search and rescue efforts; to provide permit holders and participants with information about parks and their partners; and to provide reports of activities conducted under an issued permit.

Disclosure: Voluntary. However, failure to provide the requested information may impede our ability to process your application. It is in your best interest to answer all of the questions. 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 application.

Paperwork Reduction Act Statement

The authority to collect this information is the National Underground Railroad Network to Freedom Act (P.L. 105-203). We will use this information to evaluate properties, facilities, and programs nominated for inclusion in the Network to Freedom. We may not conduct or sponsor and you are not required to respond to a collection of information unless it displays a currently valid OMB control number. Your response is required to obtain or retain a benefit. OMB has approved this collection of information and assigned control number 1024-0232.

Estimated Burden Statement

Public reporting for this collection of information is estimated to average 40 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Information Collection Officer, National Park Service, 12201 Sunrise Valley Drive (MS-242), Reston, VA 20192. Please do not send your completed application to this address.

RECORDS RETENTION:  PERMANENT.  Transfer permanent special media, and electronic records along with any finding aids or Page 1 of 15

descriptive information (including linkage to the original file) and related documentation by calendar year to the National Archives

when 3 years old. (Item 7A.2.) (N1-79-08-6))