Form 10-660A Commercial Use Authorization Monthly Report and Instruct

NPS Form 10-660A OMB Control No. 1024-0268

National Park Service Expiration Date: XX/XX/XXXX

M ONTHLY REPORT

COMMERCIAL USE AUTHORIZATION

[Park/Area Name]

[Name], CUA Coordinator

[CUA Coordinator Phone Number]

For       /      

^{(Month / Year)}

NOTE: This form is optional and only to be used for monthly statistical reporting. A separate NPS Form 10-660, “Annual Report: is required for all Commercial Use Authorizations (CUAs).

1. CUA INFORMATION:

CUA Number:      

Services Provided: (As it appears on your authorization.)

     

2. CONTACT INFORMATION:

Holder Name: Contact Person (if different) Contact Person (if different)

           

Business Name Email (business)

           

Mailing Address

(Street Address) Email (contact person)

           

(City, State, Zip Code)

     

Phone Fax

           

VISITOR USE INFORMATION

3. VISITORS AND/OR TRIPS:

Enter the number of clients serviced within the park over the past year:      

Enter the number of trips your company made to the park over the past year:      

4. LENGTH OF STAY:

Enter the average length of time your clients were in the park as a result of the service you provided (if applicable). For day trips, show the average number of hours that you spend in the park per trip. For overnight trips show the average number of nights that you spend in the park per trip from the first travel day to the last day exiting the park.

Average hours per trip:      

(Trips that use lodging outside of the park are considered day trips.)

Average number of nights per trip:      

(If provided, use table below to report total visitor use numbers.)

[Note: Park may modify and insert appropriate table for reporting visitor use information (See “Attachment A”).

INJURY INFORMATION

5. Did any reportable injuries occur during your trips this year? Yes No

If “Yes”, please use a separate sheet of paper to report the date of the incident and a brief statement of the incident. Include a description of the activity taking place at the time of the injury, the type of injury, and the action taken to provide patient care. Please include the sex and age of the patient (omit the patient’s name). A reportable injury involves any medical incident or injury requiring medical aid beyond Basic First Aid and/or when a request for medical aid/rescue assistance is made. You do not need to send in a report if you have already done so.

6. SIGNATURE: False, fictitious or fraudulent statements or representations made in this report may be grounds for denial or revocation of the Commercial Use Authorization and may be punishable by fine or imprisonment (U.S. Code, Title 18, Section 1001). Authorized Agents must attach proof of authorization to sign below.

By my signature, I hereby attest that all my statements and answers on this form and any attachments are true, complete, and accurate.

Signature Date

           

Printed Name Title

NOTICES

Privacy Act Statement

Authority: The authority to collect information on the attached form is derived from 16 U.S.C. 5966, Commercial Use Authorizations.

Purpose: The purposes of the system are (1) to assist NPS employees in managing the National Park Service Commercial Services program allowing commercial uses within a unit of the National Park System to ensure that business activities are conducted in a manner that complies with Federal laws and regulations; (2) to monitor resources that are or may be affected by the authorized commercial uses within a unit of the National Park System; (3) to track applicants and holders of commercial use authorizations who are planning to conduct or are conducting business within units of the National Park System; and (4) to provide to the public the description and contact information for businesses that provide services in national parks.

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 the National Park Service as a routine use pursuant to 5 U.S.C. 552a(b)(3) to other Federal, State, territorial, local, tribal, or foreign agencies and other authorized organizations and individuals 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: Providing your information is voluntary, however, failure to provide the requested information may impede the processing of your commercial use authorization application.

Paperwork Reduction Act Statement

In accordance with the Paperwork Reduction Act (44 U.S.C. 3501), please note the following. This information collection is authorized by The Concession Management Improvement Act of 1998 (54 U.S.C. 101911). Your response is required to obtain or retain a benefit in the form of a Commercial Use Authorization. We will use the information you submit to evaluate your impact to park resources and compliance with park regulations and limitations. We may not conduct or sponsor and you are not required to respond to a collection of information unless it displays a currently valid Office of Management and Budget control number.

Estimated Burden Statement

We estimate that it will take approximately 1.25 hours to prepare a report, including time to review instructions, gather and maintain data, and complete and review the report. 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 Rm. 2C114, Reston, VA 20192. Please do not submit your form to this address, but rather to the address at the top of the form.

A report is required for each Commercial Use Authorization (CUA) issued. These instructions correspond to the numbered questions in Form 10-660A.

1. Enter the CUA number and the service the holder is authorized to provide as it appears on the CUA.

2. Enter the contact information for the holder and primary contact as written on the CUA.

3. Enter the number of clients who made use of the commercial services provided under this CUA. Note: If you already submit monthly reports, we only require you to add the monthly reports together.

4. Enter the average number of hours or days a customer spends in the park engaging in your service.

5. Provide details of any reportable injuries incurred by the holder, the employees of the holder, or clients within the park during the term of this CUA.

6. Signature of business owner or authorized agent.

ATTACHMENT A

CUA MONTHLY REPORT

Reporting Table