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

Research Permit and Reporting System Applications and Reports (36 CFR 2.1 and 2.5)

Form 10-741A Application for Scientific Research and Collecting Permit

Application for Scientific Research and Collecting Permit (private)

OMB: 1024-0236

Document [pdf]
Download: pdf | pdf
NPS Form 10-741A (Rev. 06/2020)
National Park Service

OMB Control No. 1024-0236
Expiration Date ##/##/20##

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
Previously assigned NPS study number:
Renewal of a previously issued permit
Previously assigned NPS permit number:
Modification of a previously issued permit
Contact Information for the Current Principal Investigator
First Name
Last Name
Office Email Address of Principal Investigator:
Dr.
Ms.
Mr.
Mrs.
Mailing Address

City

Name of the Current Institution Represented:

State
Office Phone

Alternative Phone

Zip Code

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
Initial starting date of the study:

Field Schedule
Date to begin study within the park this application year:

Estimated date the entire study may end:

Date to end study within the park this application year:
Will field study need to continue within the park next year?

Activity Type: (select one)

Research

Inventory

Monitoring

Yes

No

Other:

Do you anticipate receiving funding assistance from the U.S. Federal Government for this study?
If “Yes,” specify the agency(s):
Where will data, maps, photos, etc. (not specimens) reside upon completion of this study?

Yes

No

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.)

RECORDS RETENTION: TEMPORARY. Destroy/delete 3 years after closure. (NPS Records Schedule, Resource Management and
Lands (Item 1D) (N1-79-08-1))

Page 1 of 4

NPS Form 10-741A (Rev. 06/2020)
National Park Service

OMB Control No. 1024-0236
Expiration Date ##/##/20##

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 Received

Date

FOR NATIONAL PARK SERVICE USE ONLY
Assigned Study Number
Assigned Permit Number

Page 2 of 4

OMB Control No. 1024-0236
Expiration Date ##/##/20##

NPS Form 10-741A (Rev. 06/2020)
National Park Service

APPENDIX A: PROPOSED REPOSITORY FOR COLLECTED SPECIMENS
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.

A principal investigator has requested permission to collect specimens for permanent retention in whole or in part and has requested
that the specimens and/or material originating from such specimens be loaned by the U.S. National Park Service (NPS) to a repository
that is not administered by the NPS. The principal investigator has been instructed to obtain the signature of the repository official(s) as
part of the permit application. The following information should be completed and provided to the principal investigator. The principal
investigator is responsible for ensuring the original signed form (or fax of the signed form) is received by the appropriate Park Research
Coordinator. Each non-NPS institution proposed to receive loaned specimens or material originating from such specimens must
complete this form. Note that all specimens collected and material originating from such specimens remain Federal property.
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

Name of Responsible Official (please print)

Date

Title of Responsible Official (please print)

Page 3 of 4

NPS Form 10-741A (Rev. 06/2020)
National Park Service

OMB Control No.
1024-0236 Expiration Date
##/##/20##

NOTICES
Privacy Act Statement
Authority: 54 U.S.C. 100101, National Park Service Organic Act; 54 U.S.C. 100751(a), Regulations; 54 U.S.C. 100705, National Parks
Omnibus Management Act, Availability of System units for scientific study.
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, P.L. 105-391, Sections, 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. (MS242), Reston, VA 20192. Please do not send your completed application to this address.

Page 4 of 4


File Typeapplication/pdf
File Modified2020-06-10
File Created2020-06-04

© 2024 OMB.report | Privacy Policy