Form 10-741A Application for a Scientific Research and Collecting Per

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

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

APPLICATION FOR SCIENTIFIC RESEARCH AND COLLECTING 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 Current Principal Investigator
Dr. Ms. Mr. Mrs.	First Name	Last Name					Office Email Address of Principal Investigator:
	     	     					     
Mailing Address				City					State	Zip Code
     				     					     	     
Name of the Current Institution Represented:						Office Phone		Alternative Phone	Office Fax
     						     		     	     
Additional Investigators or Key Field Assistants: (first name, last name, office phone, office email)
     
Scientific Study Information
Project Title: (maximum 300 characters)
     
Purpose of the study: (maximum 4,000 characters)
     
Does your study propose to involve any of the following? (check all that apply)
Handle Live Vertebrates T&E Species Migratory Birds Marine Mammals Unmanned Aircraft Designated Wilderness Hazardous Activity Ground Disturbance
Summary of Proposed Field Methods and Activities: (extract from the study proposal, where appropriate - maximum 4,000 characters)
     
Study Schedule			Field Schedule
Initial starting date of the study:       Estimated date the entire study may end:      			Date to begin study within the park this application year:       Date to end study within the park this application year:       Will field study need to continue within the park next year? Yes No
Activity Type: (select one) Research Inventory Monitoring Other:      
Do you anticipate receiving funding assistance from the U.S. Federal Government for this study? Yes No If “Yes,” specify the agency(s):      
Where will data, maps, photos, etc. (not specimens) reside upon completion of this study?
     
Location(s) Where You Propose Activities Will Take Place Within This National Park System Area:
     
Your Proposed Method of Access: (vehicles, aircraft, boat, snowmobile, foot, etc.)
     

Handling or Collection of Specimens
Would you like to handle or collect specimens? Yes No
If you respond “Yes,” please complete this entire section of the application (otherwise you may skip the remainder of this section). Note that all specimens collected and material originating from such specimens remain Federal property.
Scientific description of specimens to be handled or collected: (include taxonomic group or name, or type of material; sample size, quantity, frequency, and location)
     
Proposed disposition of specimens identified for handling or collection and material originating from such specimens: (mark all that apply)
Temporarily captured or handled (may include marking) and then released undamaged in place Temporarily retained, then destroyed through analysis or discarded after analysis (If your analysis later determines that temporarily retained specimens or material originating from such specimens in fact warrant permanent retention, contact the park research coordinator for further instructions)
If you propose that specimens and/or material originating from such specimens be retained permanently, they will become part of National Park Service (NPS) collections. You may request that such specimens and/or material originating from such specimens be loaned to one or more non-NPS institutions for management. If you do make this request, you accept responsibility for obtaining and submitting to NPS the signature of the official at each proposed repository using the form attached as Appendix A.
Permanently retained in NPS collection, maintained in NPS repository Permanently retained in NPS collection, maintained in one or more non-NPS repositories identified in attached Appendix A (complete and submit an Appendix A for each proposed repository)
Certification
I certify that this application is accurate and complete. I understand a formal study (research) proposal for new or modified studies must be provided to the National Park Service before this application can be considered. I authorize the National Park Service to seek peer reviews of my proposal.
Signature of Principal Investigator			Date
FOR NATIONAL PARK SERVICE USE ONLY
Date Received	Assigned Study Number	Assigned Permit Number

Principal Investigator	Office Phone			Office Fax	Office Email Address
     	     			     	     
Project Title: (maximum 300 characters)
     
Scientific description of collected specimens and/or material originating from such specimens proposed to be loaned to the non-NPS institution identified below: (include taxonomic group or name, or type of material; sample size, quantity, frequency, and location)
     
Organization Information
Non-NPS institution where specimens and/or material originating from such specimens identified in the box, above, are proposed to be deposited:
Institution	Office Phone			Office Fax	Responsible Official Email Address
     	     			     	     
Address		City					State	Zip Code
     		     					     	     
This organization concurs with the proposal that collected specimens and/or material originating from such specimens identified above be loaned to this institution for the purposes of storage, management, and research subject to the “General Permit Conditions” and the terms of applicable National Park Service loan agreements (available from the park).
Signature of Responsible Official at Custodial Institution						Date
Name of Responsible Official (please print)			Title of Responsible Official (please print)
     			     

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 scientific research and collecting 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 1.38 hours 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 6

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