Form 10-741D PERMITTEE FIELD CHECK-OUT REPORT

NPS Form 10-741D (07/2020)
National Park Service

OMB Control No. 1024-0236
Expiration Date Requested

PERMITTEE FIELD CHECK-OUT REPORT
If you are not using the automated system supporting this report process,
please fill out the relevant part of this form and return it to the appropriate park.
All or some of the information you provide may become available to the public.

Permit Number
Field Start Date

Field End Date

Permittee Field Check-in Report
Field Contact Name(s)

Field Contact Information
Field Contact Phone Type(s)

Field Contact Phone Number(S)

Residence during field work trip

Number of persons in field work group

Vehicle Make

Vehicle model

Vehicle License Plate number

Field Work Information
Name(s) of field work site(s)
Planned collections on this field work trip
Check all permissions that apply
We have received advanced permission to conduct field work during night time hours (e.g. circadian study).
We have a backcountry camping permit for this trip.
We have permission to deploy equipment (left unattended) in the field during this trip.
We have received special permission to work in public view in the field and plan to do so during this trip.
We have an approved over fight (aerial survey, telemetry flights, remote sensing, etc.) scheduled for this trip.
We have permission to survey park visitors and plan to do so during this trip
We have permission to conduct scientific studies in wilderness or closed areas and plan to do so during this trip

Permittee Field Check-out Report
Field Start Date

Field Work and Field Site Information
Field End Date

Names of field work site(s)
GIS or specific coordinate location of each field site
Number of days at each site

Number of researchers at each site

Equipment left at each site

Number of days equipment left at each site

Types and quantities of specimens from each site visited
Other Comments

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

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NPS Form 10-741C (Rev. 03/2017)
National Park Service

OMB Control No. 1024-0236
Expiration Date Requested

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 reduce the level of safety in the field of the scientific
team, may lead to unnecessary impact to park resources or visitor enjoyment, and may lead the park to revoke the 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, failure to provide the requested
information may reduce the level of safety in the field of the scientific team, may lead to unnecessary impact to park resources or visitor
enjoyment, and may lead the park to revoke the permit. 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 10 Minutes per response for each of the check-in and check-out portions
of this form, 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.

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