3-1383-R Research and Monitoring Special Use Application

FWS Form 3-1383-R (Rev. 03/2020) OMB Control No. 1018-0102

U.S. Department of the Interior Expires ##/##/####

RESEARCH AND MONITORING

SPECIAL USE PERMIT

National Wildlife Refuge System

Refuge Name:

Address:

Attn: (Refuge Official)

E-Mail:

Phone #:

Note: We do not require all information for each Research project. See instructions at the end of the notice and contact the refuge to determine applicability of a particular item. Attach additional sheets if the text spaces provided are inadequate.

1a) Identify the type of Permit you are applying for: New Renewal Modification Other

1b) Have you applied, or do you intend to apply, to any other refuges for this same activity? Yes No

1c) If yes, which refuges?

Applicant Information

2) Principal investigator: 3) Is curriculum vitae or resume attached? Yes No

4a) Affiliation/Sponsoring Organization:

4b) Relationship to affiliation/sponsoring organization (professor, staff, student, etc.):

5) Physical Address:

City/State/Zip:

6) Mailing Address: (if different than above)

City/State/Zip:

7) Phone #: 8) Fax #: 9) E-mail:

10) List known assistants/subcontractors/subpermittees: (Only required if the assistants/subcontractors/subpermittees will be operating on the refuge without the permittee being present.)

Name	Address	Phone #

Project Information

11) Title of project:

12) Is a full research proposal attached? Yes No

Note: Depending on the research and monitoring project for which you are requesting a permit, we may ask you for the following project information (13 -25) if it is not included in your research proposal, or if you have not provided a full research proposal with this application. Please contact the specific refuge where the activity is being conducted to determine what information is required.

Attach additional sheets to the application if the text spaces provided are inadequate.

13) Describe project by specifically identifying timing, frequency, and how the project is expected to proceed:

14) Specifically identify location(s) and/or attach a map for the project: (GPS location(s) preferred)

15) Identify species or habitats being studied:

16) Purpose/hypothesis:

17) Expected benefits of research/monitoring:

18) Briefly describe project history and context of research/monitoring project:

19) Briefly describe project’s relationship to other research/monitoring projects either known of or conducted by the applicant:

20) Identify the types of specimen collections to be taken (see specimen collection clause in the instruction section #20) or data to be collected during the proposed project:

21) List other cooperators and institutions involved in the project:

22) Generally identify the anticipated timeline for analysis, write-up and publication:

23) For research involving animals, attach an Assurance of Animal Care Form or an approval from an Institutional Animal Care and Use Committee? Is a form or approval attached? Yes No N/A

License/Insurance/Certifications/Permits

Note: Contact the specific refuge office where the research project is going to be conducted to determine if any type of license, insurance, certification(s), or permit(s) will be required. We may process this Special Use Permit while the applicant obtains them.

Attach additional sheets to the application if the text spaces provided are inadequate.

24a) List and attach copies of any licenses you have for equipment operation (i.e., aviation or commercial boats), pesticide applications, transporters) or others if required:

License Type	Number	Expiration Date (if applicable)

24b) List and attach copies of any insurance you have (i.e general liability, flight/grounding, contaminants, medical evacuation, or others if required:

Insurance Type	Carrier	Expiration Date (if applicable)

24c) List and attach copies of any certifications you have, such as rat free, hull inspections, CPR/First Aid, or others if required:

Certificate Type	Expiration Date (if applicable)

Permit Type	Permit Number	Expiration Date (if applicable)

24d) List and attach copies of any other Federal, State, or Tribal permits if required:

Logistics and Transportation Attach additional sheets if the text spaces provided are inadequate.

25a) Does project require personnel to stay overnight on the refuge? Yes No

25b) If yes, how many? And list known personnel involved in overnight stay below:

List Names	List Names	List Names	List Names

26) Specifically describe all major instrumentation/equipment/gear (i.e. use of drones) and materials used, if applicable or required:

27a) Provide details and schedule for the installation of instrumentation:

27b) Provide details and schedule for the removal of instrumentation:

27c) If instrumentation is permanent, describe need:

30d) Specifically describe onsite transportation:

27d) If instrumentation requires a maintenance schedule, describe needs and schedule:

30d) Specifically describe onsite transportation:

27e) Provide a data collection schedule:

30d) Specifically describe onsite transportation:

28) Provide logistical arrangements for offsite transportation of samples:

30d) Specifically describe onsite transportation:

29a) Provide detailed information on the logistics for onsite, intersite, and/or ship-to-shore transportation to or on the refuge, if required:

29b) Provide descriptions, license plate and/or identification numbers of vehicles used for onsite transportation, if required:

Vehicle Type	Plate/I.D./Registration #	Vehicle Type	Plate/I.D./Registration #

Vehicle Type	Plate/I.D./Registration #	Vehicle Type	Plate/I.D./Registration #

29c) Provide descriptions, license plate and/or identification numbers of vehicles used for intersite transportation, if required:

Vehicle Type	Plate/I.D./Registration #	Vehicle Type	Plate/I.D./Registration #

29d) Provide descriptions, license plate and/or identification numbers of vehicles used for ship-to-shore transportation, if required

30a) Is fuel cache needed? Yes No N/A 30b) Provide specific location(s) of fuel caches: (GPS coordinates preferred)

31) Attach Safety Plan if required. Is Safety Plan attached? Yes No N/A

Work and Living Accommodations

32) Specifically describe onsite work and/or living accommodations, including spike camps:

33) Specifically describe on or offsite hazardous material storage or other on or offsite material storage space: (Including on and offsite fuel caches.)

Sign, date, and print this form and return it to the refuge for processing. By signing this application, I agree my operations will conform to the information I have provided in this application, and I understand that any deviations or changes to this information must receive prior written approval.

34) Signature of Applicant: _______________________________________Date of Application: ___________________________________

NOTICES

No Members of Congress or Resident Commissioner shall participate in any part of this contract or to any benefit that may arise from it, but this provision shall not pertain to this contract if made with a corporation for its general benefit.

The Permittee agrees to be bound by the equal opportunity “nondiscrimination in employment” clause of Executive Order 11246.

PRIVACY ACT STATEMENT

Authority: The information requested is authorized by the National Wildlife Refuge System Administration Act (16 U.S.C. 668dd-ee) and the Refuge Recreation Act (16 U.S.C. 460k-460k-4).

Purpose: To collect the applicant’s information to process permits allowing for: research and monitoring activities by students, universities, or other non-FWS organizations.

Routine Uses: The information will be used by the refuge’s administrative office for processing Research and Monitoring Special Use permits. More information about the routine uses maybe found in the Systems of Records Notice, FWS-5 National Wildlife Refuge Special Use Permits.

Disclosure: Providing the information is voluntary. However, submission of information is required to process and approve research and monitoring activity usage on the National Wildlife Refuge System.

PAPERWORK REDUCTION ACT STATEMENT

We are collecting this information subject to the Paperwork Reduction Act (44 U.S.C. 3501) to evaluate the qualifications, determine eligibility, and document permit applicants and to respond to requests made under the Freedom of Information Act and the Privacy Act of 1974. The information that you provide is required to obtain or retain a benefit; however, failure to provide all required information is sufficient cause for the U.S. Fish and Wildlife Service to deny a permit. False, fictitious, or fraudulent statements or representations made in the application may be grounds for revocation of the Special Use Permit and may be punishable by fine or imprisonment (18 U.S.C. 1001). According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. OMB has approved this information collection and assigned control number 1018-0102.

ESTIMATED BURDEN STATEMENT

The public reporting burden for this information collection varies based on the requested specific refuge use. We estimate the relevant public reporting burden for the Commercial Activity Special Use Permit Application form (Research and Monitoring) to average 5 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 Service Information Clearance Officer, U.S. Fish and Wildlife Service, 5275 Leesburg Pike, MS: PRB (JAO/3W), Falls Church, VA 22041-3803, or via email to Info_Coll@fws.gov. Please do not send your completed form to this address.

GENERAL CONDITIONS AND REQUIREMENTS

1) Responsibility of Permittee: We shall consider the permittee, by operating on the premises, to have accepted these premises with all facilities, fixtures, or improvements in their existing condition as of the date of this permit. At the end of the period specified or upon earlier termination, the permittee shall give up the premises in as good order and condition as when received except for reasonable wear, tear, or damage occurring without fault or negligence. The permittee will fully repay the Service for any and all damage directly or indirectly resulting from negligence or failure on his/her part, and/or the part of anyone of his/her associates, to use reasonable care.

2) Operating Rules and Laws: The permittee shall keep the premises in a neat and orderly condition at all times, and shall comply with all municipal, county, and State laws applicable to the operations under the permit as well as all Federal laws, rules, and regulations governing national wildlife refuges and the area described in this permit. The permittee shall comply with all instructions applicable to this permit issued by the refuge official in charge. The permittee shall take all reasonable precautions to prevent the escape of fires and to suppress fires and shall render all reasonable assistance in the suppression of refuge fires.

3) Use Limitations: The permittee’s use of the described premises is limited to the purposes herein specified and does not, unless provided for in this permit, allow him/her to restrict other authorized entry onto his/her area; and allows the U.S. Fish and Wildlife Service to carry on whatever activities are necessary for: (1) protection and maintenance of the premises and adjacent lands administered by the U.S. Fish and Wildlife Service; and (2) the management of wildlife and fish using the premises and other U.S. Fish and Wildlife Service lands.

4) Transfer of Privileges: This permit is not transferable, and no privileges herein mentioned may be sublet or made available to any person or interest not mentioned in this permit. No interest hereunder may accrue through lien or be transferred to a third party without the approval of the Regional Director of the U.S. Fish and Wildlife Service and the permit shall not be used for speculative purposes.

5) Compliance: The U.S. Fish and Wildlife Service’s failure to require strict compliance with any of this permit’s terms, conditions, and requirements shall not constitute a waiver or be considered as a giving up of the U.S. Fish and Wildlife Service’s right to thereafter enforce any of the permit’s terms or conditions.

6) Conditions of Permit not Fulfilled: If the permittee fails to fulfill any of the conditions and requirements set forth herein, the U.S. Fish and Wildlife Service shall retain all money paid under this permit to be used to satisfy as much of the permittee’s obligation as possible.

7) Payments: All payment shall be made on or before the due date to the local representative of the U.S. Fish and Wildlife Service by a postal money order or check made payable to the U.S. Fish and Wildlife Service.

8) Termination Policy: At the termination of this permit the permittee shall immediately give up possession to the U.S. Fish and Wildlife Service representative, reserving, however, the rights specified in paragraph 11 below. If he/she fails to do so, he/she will pay the U.S. Fish and Wildlife Service, as liquidated damages, an amount double the rate specified in this permit for the entire time possession is withheld. Upon yielding possession, we will still allow the permittee to reenter as needed to remove his/her property as stated in paragraph 11 below. The acceptance of any fee for the liquidated damages or any other act of administration relating to the continued tenancy is not to be considered as an affirmation of the permittee’s action nor shall it operate as a waiver of the U.S. Fish and Wildlife Service’s right to terminate or cancel the permit for the breach of any specified condition or requirement.

9) Revocation Policy: The Regional Director of the U.S. Fish and Wildlife Service may revoke this permit without notice for noncompliance with the terms hereof, or for violation of general and/or specific laws or regulations governing national wildlife refuges, or for nonuse. It is at all times subject to discretionary revocation by the Director of the Service. Upon such revocation the U.S. Fish and Wildlife Service, by and through any authorized representative, may take possession of said premises for its own and sole use, and/or may enter and possess the premises as the agent of the permittee and for his/her account.

10) Damages: The U.S. Fish and Wildlife Service shall not be responsible for: any loss or damage to property including but not limited to crops, animals, and machinery; injury to the permittee or his/her relatives or to the officers, agents, employees, or any other(s) who are instructed to be on the premises; the sufferance from wildlife or employees or representatives of the U.S. Fish and Wildlife Service carrying out their official responsibilities. The permittee agrees to hold the U.S. Fish and Wildlife Service harmless from any and all claims for damages or losses that may arise to be incident to the flooding of the premises resulting from any associated Government river and harbor, flood control, reclamation, or Tennessee Valley Authority activity.

11) Removal of Permittee’s Property: Upon the expiration or termination of this permit, if all rental charges and/or damage claims due to the U.S. Fish and Wildlife Service have been paid, the permittee may, within a reasonable period as stated in the permit or as determined by the U.S. Fish and Wildlife Service official in charge, but not to exceed 60 days, remove all structures, machinery, and/or equipment, etc., from the premises for which he/she is responsible. Within this period the permittee also must remove any other of his/her property including his/her acknowledged share of products or crops grown, cut, harvested, stored, or stacked on the premises. Upon failure to remove any of the above items within the aforesaid period, they shall become the property of the U.S. Fish and Wildlife Service. .

INSTRUTIONS FOR COMPLETING APPLICATION

You may complete the application portion verbally, in person, or electronically and submit to the refuge for review. Note: Please read instructions carefully as not all information is required for each activity. Contact the specific refuge where the activity will take place if you have questions regarding the applicability of a particular item. We may add special conditions or permit stipulations to permit prior to approval.

1a-1c) Identify if permit application is for new, renewal, or modification of an existing permit, whether or not you have or will be applying to another refuge for the same activity, and for which refuge(s). Permit renewals may not need all information requested. Contact the specific refuge headquarters office where the activity is going to be conducted to determine applicability of this requirement.

2-3) Provide principal investigator or applicant full name. Attach principal investigator’s Curriculum Vitae or Resume, if required. Permit renewals generally do not require a Curriculum Vitae or Resume if the project is a continuation of a previously issued permit being conducted by the same investigator. Contact the specific refuge office to determine applicability of this requirement.

4-9) Provide investigator’s physical and/or mailing address, phone, fax, e-mail, affiliation and/or sponsoring organization, and relationship to affiliation or organization (title, professor, student, etc.).

10) Provide the names and addresses of assistants, subcontractors, or subpermittees. We may require names and addresses if the assistants, subcontractors or subpermittees will be operating on the refuge without the permittee being present. Volunteers, assistants, subcontractors, or subpermittees accompanied by the permittee need not be identified.

11) Provide title of research or monitoring project.

12a-12b) Attach a full research or monitoring proposal, if required. Permit renewals generally do not require a project proposal if the project is a continuation of a previously issued permit being conducted by the same investigator. Contact the specific refuge office to determine applicability of this requirement.

13) Provide detailed information on the activity, including timing, frequency, how the project is expected to proceed, etc. Permit renewals may not need activity description, if the activity is unchanged from previous permit. Most repetitive research projects do not require an activity description for each visit to the refuge. Contact the specific refuge office to determine applicability of this requirement.

14) Identify specific location (GPS coordinates preferred) if not a named facility, and/or attach a map of the location. Permit renewals may not require a location if the project is essentially unchanged from the previous permit. Contact the specific refuge office to determine applicability of this requirement.

15) Identify species or habitats being studied.

16-17) Specifically identify purpose or hypothesis of the research or monitoring project and describe expected benefits. Permit renewals may not need to identify purpose or hypothesis if the project is a continuation of a previously issued permit being conducted by the same investigator. Contact the specific refuge office to determine applicability of this requirement.

18) Briefly describe project history and context. Permit renewals should describe previous research activities as part of a previously issued permit being conducted by the same investigator. Contact the specific refuge office to determine applicability of this requirement.

19) Briefly describe project’s relationship to other research/monitoring projects either known of or conducted by the applicant, if applicable. Include a brief statement of how the research or monitoring permit being applied for will add to or supplement other ongoing research or monitoring on the same, or related, species or habitats. Contact the specific refuge office to determine applicability of this requirement.

20) Identify specimen collections to be taken or types of data to be collected. You may use specimens collected under this permit, any components of any specimens (including natural organisms, enzymes, genetic materials or seeds), and research results derived from collected specimens for scientific or educational purposes only, and not for commercial purposes unless you have entered into a Cooperative Research and Development Agreement (CRADA) with us. We prohibit the sale of collected research specimens or transfers to third parties for commercial purposes. Breach of any of the terms of this permit will be grounds for revocation of this permit and denial of future permits. Furthermore, if you sell or otherwise transfer for commercial purposes collected specimens, any components thereof, or any products or research results developed from such specimens or their components without a CRADA, you will pay us a royalty rate of 20 percent of gross revenue from such sales. In addition to such royalty, we may seek other damages and injunctive relief against you. Permit renewals may not need to identify samples taken if the project is a continuation of a previously issued permit being conducted by the same investigator. Contact the specific refuge office to determine applicability of this requirement.

21) List other cooperators and institutions involved in the project, if applicable. Contact the specific refuge office to determine applicability of this requirement.

22) Generally, identify the anticipated time line for analysis, write-up, and publication of project results. Include whether the project is a single, or multiple year project. Identification of an actual publication where the results are printed is not necessary. However, applicants should include the anticipated dissemination of project results. Contact the specific refuge office to determine applicability of this requirement.

23) Check box acknowledging a completed Assurance of Animal Care Form or an Institutional Animal Care and Use Committee (or equivalent) that has granted approval has been completed, and has been submitted to refuge station, if required. Contact the specific refuge office to determine applicability of this requirement.

24a-24d) Specifically identify types and numbers of licenses, insurance, certifications, and other State, Federal, or Tribal permits if required. Contact the specific refuge headquarters office where the project is going to be conducted to determine applicability of these requirements, and to coordinate the simultaneous applications of any of these requirements while this Special Use Permit is being processed.

25a-25b) Provide the number of and/or name(s) of any personnel required to stay overnight on the refuge, if applicable.

26) Identify all equipment (including drones) and materials that will be used, if required. Permit renewals may not require a list of equipment if the project is essentially unchanged from a previously issued permit. Contact the specific refuge office to determine applicability of this requirement.

27a-27e) Identify types and schedule(s) of installation of any instrumentation, data collection, and maintenance schedule of instrumentation, if required. Permit renewals may not require a list of equipment if the project is essentially unchanged from a previously issued permit. However, schedules of installation of any instrumentation, data collection, and maintenance schedule of instrumentation may still be required. Contact the specific refuge headquarters office where the project is going to be conducted to determine applicability of this requirement.

28) Identify logistical arrangements for offsite transportation of samples taken, if applicable.

29a-29d) Describe and provide vehicle descriptions and license plate or identification numbers of all vehicles, including boats and airplanes, if required. Motor vehicle descriptions are only required for permittee vehicle, and/or if the vehicle will be operated on the refuge without the permittee being present. Motor vehicles that are accompanied by the permittee as part of a group (convoy) activity need not be identified if cleared in advance by refuge supervisor. Specifically describe ship-to-shore, intersite (between islands, camps, or other sites) and onsite transportation mechanisms, and license plate or identification numbers, if required.

30a-30b) Identify specific location(s) of fuel cache(s) (GPS coordinates preferred), if required.

31a-31b) Attach safety plan, if required. Contact the specific refuge office to determine applicability of this requirement.

32) Specifically describe onsite work and/or living accommodations, if required. Include descriptions and locations (GPS coordinates preferred) of spike camps or other remote work and/or living accommodations that are not part of the base of operations. Contact the specific refuge office to determine applicability of this requirement.

33) Specifically describe onsite and offsite hazardous material storage, or other onsite material storage space (including on and offsite fuel caches), if required. Contact the specific refuge office to determine if descriptions of hazardous material storage or other onsite material storage are required.

34) Sign, date, and print the application. Click on the Print button to print the application (if using the fillable version). The refuge official will review and, if approved, fill out the remaining information, sign, and return a copy to you for signature and acceptance.

This application form is not valid as a permit

but may be used as a reference document attached to the official permit.

Only official refuge personnel may assign a valid permit number and permit term

to this application form after the permit has been approved.