Form 10-741b Application for a Science Education Permit

NPS Form 10-741B (Rev. 03/2017) OMB Control No. 1024-0236

National Park Service Expiration Date ##/##/2020

APPLICATION FOR SCIENCE EDUCATION PERMIT

If you are not using the automated system supporting this report process,

please fill out this form and return it to the appropriate park.

All or some of the information you provide may become available to the public.

Name of the National Park System Area You Are Applying To:
     
Select One of the Following:					Please Enter Numbers for Permit Renewal or Modification Requests:
New application Renewal of a previously issued permit Modification of a previously issued permit					Previously assigned NPS study number:       Previously assigned NPS permit number:      
Contact Information for the Activity Leader (Responsible Official)
Dr. Ms. Mr. Mrs.	First Name	Last Name					Office Email Address of Responsible Official:
	     	     					     
Mailing Address				City					State	Zip Code
     				     					     	     
Name of the Current Institution Represented:						Office Phone		Alternative Phone	Office Fax
     						     		     	     
Provide the first and last name of the person expected to back up the activity leader during visits to the park:
     
Proposed Science Education Activity Information
Name or Title of Proposed Science Education Activity: (maximum 300 characters)
     
Purpose and Brief Description of the Activity: (maximum 4,000 characters)
     
Science Education Permit Application:
Does our study propose to involve any of the following (check all that apply): Handle Live Vertebrates Migratory Birds Unmanned Aircraft Designated Wilderness Hazardous Activity Ground Disturbances
Proposed Field Methods and Activities: (Summarize from the proposal, where appropriate - maximum 4,000 characters)
     
Planned number of instructors and leaders:       Planned number of students:      			Indicate educational levels of this activity: (select all that apply) K-6 7-12 Higher
Activity Schedule			Field Schedule
Initial starting date of the activity:       Estimated date the entire activity may end:      			Date to begin activity within the park this application year:       Date to end activity within the park this application year:       Number of times the field activity will be conducted this application year:       Will activity need to continue within the park next year? Yes No
Do you anticipate seeking any waiver of fees or other NPS assistance in conjunction with this activity? Yes No If “Yes,” please explain:      
Location(s) Where You Propose Activities Will Take Place Within This National Park System Area:
     
Your Proposed Method of Access: (bus, van, car, other vehicle, aircraft, boat, snowmobile, foot, other)
     

Handling or Collection of Specimens
Would you like to temporarily handle or collect specimens? Yes No
If you respond "No," you will not be authorized to handle or collect specimens. Please skip to the Certification section of the application. If you respond “Yes,” please complete the next section of the application before moving to the Certification section.
Scientific description of specimens to be handled or collected: (include taxonomic group or name, or type of material; sample size, quantity, frequency, and location)
A) Specimens to be handled and returned unmodified to the place of collection:
     
B) Specimens to be handled and used up in the activity:
     
Certification
I certify that this application is accurate and complete. I understand a formal science education activity proposal may have to be provided to NPS before this application can be considered. I authorize the National Park Service to seek peer reviews of my proposal.
Signature of Activity Leader			Date
FOR NATIONAL PARK SERVICE USE ONLY
Date Received	Assigned Activity Number	Assigned Permit Number

NOTICES

Privacy Act Statement

Authority: 16 U.S.C. 1, National Park Service Organic Act; 16 U.S.C. 3, Rules and regulations of national parks, reservations, and monuments; timber; leases; 16 U.S.C. 5935, National Parks Omnibus Management Act.

Purpose: The two primary uses of the records maintained in the system are to administer scientific research and collecting within units of the National Park System, and to make Investigator’s Annual Reports available to the public.

Routine Uses: In addition to those disclosures generally permitted under 5 U.S.C.552a(b) of the Privacy Act, records or information contained in this system may be disclosed outside DOI as a routine use pursuant to 5 U.S.C. 552a(b)(3) to other federal, state, local, tribal or foreign governments and organizations, and members of the general public based on an authorized routine use when the disclosure is compatible with the purpose for which the records were compiled as described under the system of records notice for this system.

Disclosure: Voluntary, however, failure to provide the requested information may impede the processing of your application for science education permit.

Paperwork Reduction Act Statement

We are collecting this information subject to the Paperwork Reduction Act (44 U.S.C. 3501) and National Parks Omnibus Management Act of 1998 (NPOMA, Sections 201 (4), 201 (5), and 205 which govern the use of parks for study to benefit park management and broader science, and also publication of information derived from studies conducted in the National Park System. The National Park Service collects information about permit applicants and permittees to administer and document research, collecting, and reporting activities within parks. All applicable parts of the form must be completed in order for your request to be considered. Failure to provide the information may result in denial of your permit application. A Federal agency 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. OMB has approved this collection of information and assigned OMB Control No. 1024-0236.

Estimated Burden Statement

Public reporting burden for this form is estimated to average 1 hour per response, including the time it takes for reviewing instructions, gathering and maintaining data, and completing and reviewing the form. Comments regarding this burden estimate or any aspect of this form should be sent to the Information Collection Clearance Officer, National Park Service, 12201 Sunrise Valley Dr. (MS-242), Reston, VA 20192. Please do not send your completed application to this address.

RECORDS RETENTION: TEMPORARY. Destroy/delete 3 years after closure. (NPS Records Schedule, Resource Management and Page 1 of 5

Lands (Item 1D) (N1-79-08-1))